New York State Extra Benefits:
MANDATED BENEFITS
Home Health Care:
Coverage provided for Part-Time or intermittent home health care or aide service charges, for the care and treatment of a Covered Person, under the care of a Doctor, but only if Hospitalization or confinement in a nursing facility would have been required if home care was not provided. The facility providing services must be certified home health agency possessing all necessary accreditations and approved in writing by the treating physician. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Autism Spectrum Disorder Benefit:
Coverage is provided, on the same basis as any other Sickness, for treatment of Autism Spectrum Disorder. “Autism Spectrum Disorder" means a neurobiological condition that includes autism, Asperger syndrome, Rett's syndrome, or pervasive developmental disorder. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Biological Based Mental, Nervous, or Emotional Disorder Benefit:
Coverage is provided, the same as any other Sickness, for inpatient hospital treatment and out patient care for covered adults and children with biologically based mental illness and children with serious emotional disturbances. Any facility providing services must be certified to provide treatment and approved in writing by the treating physician. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Chiropractic Care Expense Benefit:
Coverage is provided for a covered persons covered charges for non-surgical treatment to remove nerve interference and its effects, which is caused by or related to Body Distortion. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Cancer Second Opinion Expense Benefit:
Coverage is provided for a Covered Persons second medical opinion by an appropriate specialist, including but not limited to a specialist affiliated with a specialty care center, in the event of a positive or negative diagnosis of cancer or a recurrence of cancer or a recommendation of a course or treatment for cancer. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Reconstructive Breast Surgery Expense Benefit:
Coverage is provided for inpatient hospital care for a Covered Person undergoing: (1) lumpectomy or a lymph node dissection for the treatment of breast cancer; or (2) mastectomy, which is covered under this plan. Coverage is limited to a time frame determined by the Covered Person’s Doctor to be medically appropriate (3) breast reconstruction surgery after a mastectomy including (3a) all stages of reconstruction of the breast on which the mastectomy has been performed and (3b) surgery and reconstruction of the other breast to produce symmetry. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Prostate Cancer Screening:
Coverage is provided to a Covered Person for the screening and diagnosis of prostate cancer, including but not limited to prostate-specific antigen testing and digital rectal examination, consistent with current medical practice. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Hospice Care Benefit:
Coverage is provided if a Doctor certifies that a Covered Person’s life expectancy is not more than 6-months, coverage is provided for services and supplies provided by a hospice. Such care must be provided to reduce or abate pain, and not for cure. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Bone Mineral Density Measurement and Test Expense Benefit:
Coverage is provided to a Covered Person for the prevention, diagnosis and treatment of osteoporosis including bone mineral density measurements and dual-energy x-ray absorptiometry and drugs and devices for bone mineral density approved by the US FDA when requested by a health care provider for a Qualified Individual. Qualified Individual means (1) previously diagnosed or having a family history (2) symptoms or conditions indicative of osteoporosis (3) on a prescribed drug regimen posing a significant risk (4) lifestyle factors posing a significant risk. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Cytologic Screening Expense Benefit:
Coverage is provided to a Covered Person for an annual cervical smear or Pap Smear test for females eighteen and older. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Mammographic Examination Expense Benefit:
Coverage is provided to a Covered Person for (a) one at any age, for a person who has a prior history of breast cancer or who has a first degree relative with a prior history of breast cancer, when recommended by a Doctor or (b) one baseline for a person age thirty-five through thirty-nine or (c) one annually for a person age forty years or older. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Diabetes Treatment:
Coverage is provided to a Covered Person for the following equipment and supplies for the management and treatment of insulin-using diabetes, non-insulin-using diabetes, and gestational diabetes: (a) blood glucose monitors and monitors designed for the visually impaired and blood glucose test strips (b) insulin pumps and all related necessary supplies (c) ketone urine testing strips (d) lancets/lancet puncture devices (e) pen delivery systems for the administration of insulin (f) Podiatric devices to prevent or treat diabetes-related complications (g) insulin syringes (h) visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
End of Life Care Expense Benefit:
Coverage is provided to a Covered Person if diagnosed with Advanced Cancer, including services provided by a facility specializing in the treatment of terminally ill patients and the attending Doctor certifies that there is no hope of reversal of the primary disease and that the Covered Person has less then 60 days to live. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
Early Intervention Services Benefit:
Coverage is provided for Early Intervention Services for children up to three years of age who are disabled or at risk of disability on the same basis as any other Sickness. Benefits paid for Early Intervention will not decrease benefits payable for other conditions. Members are reimbursed for all covered and paid charges, not to exceed the plan maximum amounts.
THIS IS LIMITED INDEMNITY COVERAGE. IT IS NOT MAJOR MEDICAL COVERAGE and is not intended to replace other medical coverage.
There is a 30-day waiting period for Sickness
A 12-month Pre-existing Condition Limitation applies to the following benefits: Hospital, including First Day Admission, Hospital Standard room, Intensive Care/Cardiac Care Unit, Surgery and Anesthesia.
Please see Exclusions and Limitations
Underwritten by United States Fire Insurance Company