N.Y. Comp. Codes R. & Regs. tit. 11 § 52.5

Current through Register Vol. 46, No. 45, November 2, 2024

Section 52.5 - Basic hospital insurance

Basic hospital insurance is an insurance policy which provides coverage subject to no deductible in excess of $500 for a period of not less than 60 days for any continuous hospital confinement of each covered person for services rendered while confined in a hospital (except as to subdivision [c] of this section) or, in the case of an article 43 corporation, for services rendered while confined in a member hospital, for necessary treatment because of sickness or injury for at least:

(a) Daily room and board, consisting of bed and board, including general nursing care and special diets, in an amount not less than the lesser of:

(1) 80 percent of the charges for semiprivate accommodations;

(2) 100 percent of the charges for semiprivate accommodations for the first 20 days of confinement and at least 50 percent of such charges for the next 40 days; or

(3) $240 per day; except that such $240 may be reduced to $165 for policies issued for delivery outside the metropolitan area.

(b) Miscellaneous hospital services, during each period of continuous hospital confinement as an inpatient, in an amount not less than 80 percent of the charges incurred, up to at least $5,000 or 20 times the daily room and board rate if specified in dollar amounts for at least:

(1) the use of operating, recovery and cystoscopic rooms and equipment;

(2) the use of intensive care or special care units and equipment to the extent not otherwise provided in the policy;

(3) diagnostic and therapeutic items, such as drugs and medications, sera, biologicals and vaccines, intravenous preparations and visualizing dyes for care in the hospital, and administration thereof, but not including those which are not commercially available for purchase and readily obtainable by the hospital;

(4) dressings and plaster casts;

(5) supplies and use of equipment in connection with oxygen, anesthesia, physiotherapy, chemotherapy, electrocardiographs, electroencephalographs, X-ray examinations and radiation therapy, laboratory and pathological examinations, blood products, except when participation in a volunteer blood replacement program is available to the insured or covered person;

(6) radiation therapy and chemotherapy; and

(7) any medical services and supplies which are customarily provided by hospitals, unless specifically excluded in the insurance or subscriber contract and the individual certificates issued in connection with group insurance.

(c) Outpatient services, consisting of:

(1) hospital services on the day surgery is performed;

(2) hospital services rendered within 24 hours after accidental injury, in an amount not less than the lesser of the reasonable charges incurred or the per-day amount provided for daily room and board if specified in dollar amounts under subdivision (a) of this section; and

(3) with respect to individual insurance written by insurers other than article 43 corporations, X-ray and laboratory tests performed in the outpatient department of a hospital, to the extent that benefits for such services would have been provided if rendered to an inpatient of the hospital.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.5