What is covered under a NY Health Insurance Plan?

New York is one of the best places to get health insurance thanks to the NY State of Health. New York has been a health reform leader, enacting several consumer-friendly protection regulations to keep New Yorkers safe. The state fully embraced Obamacare/The Affordable Care Act. New York expanded Medicaid, created a health insurance exchange, and even developed a Basic Health Plan (BHP) for those who earn too much to qualify for Medicaid but still don’t make over 200% of the poverty level.

NY Health Insurance Plan
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The Affordable Care Act allowed for the creation of Basic Health Plans (BHPs), but only Minnesota and New York developed them.

What Does Health Insurance Cover?

While different plans cover different things, the Affordable Care Act changed how health insurance works, so providers must offer coverage for ten essential benefits. Here’s what your health insurance plan will cover, no matter the provider or tier; for more information we recommend to check out the guided articles on NY Health Insurer.

  1. Ambulatory Care

Ambulatory care covers the outpatient care you receive before you are admitted to the hospital.

  • Emergency Services

The ACA dictates insurance providers have to provide coverage for any emergency care you get, no matter the hospital you are treated or the provider you have. Insurance providers can’t require you to see a specific healthcare provider in their network during an emergency.

  • Hospitalization

The hospitalization requirement covers hospital stays for planned and emergency surgery and overnight stays in the hospital. Hospital stays under 24 hours are covered as part of the ambulatory care services.

  • Prescription Medication

Every health insurance provider is required to offer coverage for prescription medications. However, the insurer can require you to try generic drugs first. These drugs are cheaper than their brand name counterparts and can be just as effective. Your doctor can request an appeal to skip generic medication if they believe those medications will be ineffective or hazardous to your health.

  • Laboratory Services

This section covers things such as blood tests, CAT scans, MRIs, and other imaging tests.

  • Pregnancy, Maternity, and Newborn Healthcare

New York health insurance covers pre-and-post-birth care. It also covers labor services for women giving birth.

  • Mental Health Care and Substance Abuse Treatments

Health insurance providers are required to offer behavioral health therapy and behavioral and mental health inpatient services. They must also provide substance abuse treatments. Insurance providers cannot place annual/lifetime spending limits on the treatment of specific diseases and conditions.

  • Preventative Health and Wellness

Preventative care covers things such as vaccinations, boosters, blood pressure, and cholesterol screenings, and screening for STDs.

  • Rehabilitation Devices and Services

This covers physical or occupational therapy. It also covers mobility aids and devices.

  1. Pediatric Care

Health insurance should cover dental and vision care for children. They are not required to provide these services for adults, however. You may have the option to choose extra dental and vision coverage as an add-on for your plan.

These are the essential services required by any ACA-compliant healthcare plan.

What Doesn’t Health Insurance Cover?

The following are things a health insurance plan typically won’t cover – at least not without a premium attached.

  1. Travel Vaccinations

Health insurance must cover necessary vaccinations and boosters, including immunizations and the flub jab. These vaccinations are often a significant part of medically necessary treatments for insurers. However, vaccinations required for international travel might not be covered under insurance.

  • Weight-Loss Surgery

There are no federal mandates covering weight loss surgery. Healthcare providers are not required to offer bariatric surgery under health insurance plans. If you feel that you, or someone on the plan, may need this surgery in the future, you should first discuss it with the health insurance provider.

  • Cosmetic Surgery

Health insurance plans only cover medical procedures considered medically necessary. This does not include cosmetic surgery or enhancements such as botox or fat reduction surgery.

  • Dental, Vision, and Hearing

Health insurance plans are only required to offer dental, vision, and hearing services to young children. Talk to your provider about getting these coverages for adults on the plan.

Keep in mind that different plans can cover different things. Read through the fine print, talk to the provider, and shop around until you find the right insurance program for you. The Affordable Care Act has made it much easier to find an affordable health insurance plan that covers everything you need, but it is always good to do some research of your own to find the best New York health insurance plan.


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