N.Y. Comp. Codes R. & Regs. tit. 11 § 52.7

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

Section 52.7 - Major medical insurance

Major medical insurance is an insurance policy which provides coverage for each covered person, to a maximum of not less than $100,000; copayment by the covered person not to exceed 25 percent; a deductible stated on a per-person, per-family, per-illness, per-benefit period, or per- year basis, or a combination of such bases, not to exceed five percent of the lowest overall maximum limit under the policy, unless the policy is written to complement underlying hospital and medical insurance, in which case such deductible may be increased by the amount of the benefits provided by such underlying insurance, for at least:

(a) daily room and board, as defined in section 52.5(a) of this Part;

(b) miscellaneous hospital services, as defined in section 52.5(b) of this Part; provided, however, that the maximum amount limitation shall not apply;

(c) surgical services, as defined in section 52.6(a) of this Part;

(d) anesthetic services, as defined in section 52.6(b) of this Part;

(e) in-hospital medical services, as defined in section 52.6(c) of this Part;

(f) mental health care consisting of coverage for diagnosis and treatment of mental illness for at least:

(1) 30 days per year of inpatient care in a hospital as defined by subdivision ten of section 1.03 of the Mental Hygiene Law;

(2) 30 outpatient visits per year at no less than $30 per visit and a yearly maximum of no less than $1,500 with reimbursement for early visits greater than or at least equal to reimbursement for subsequent visits in a facility issued an operating certificate by the Commissioner of Mental Health pursuant to the provisions of article 31 of the Mental Hygiene Law, or in a facility operated by the Office of Mental Health, or by a psychiatrist or psychologist licensed to practice in this State, or a professional corporation thereof; and

(3) outpatient crisis intervention services consisting of at least three psychiatric emergency visits per year. Upon certification, by a licensed mental health care provider whose services are covered under the policy, that a visit was the result of a psychiatric emergency (one where the person appears to have a mental illness for which immediate observation, care and treatment is appropriate and which is likely to result in serious harm to himself or others), benefits for such a visit shall be no less than $60 per visit. However, benefits provided under this paragraph may be used to reduce benefits otherwise payable under paragraph (1) or (2) of this subdivision;

(g) out-of-hospital care, consisting of physicians' services rendered on an ambulatory basis, where coverage is not provided elsewhere in the policy, for diagnosis and treatment of sickness or injury, including the cost of drugs and medications available only on the prescription of a physician, and diagnostic X-ray, laboratory services, radiation therapy, chemotherapy and hemodialysis ordered by a physician; and

(h) prosthetic appliances, meaning artificial limbs or other prosthetic appliances (including replacements thereof which are functionally necessary), and rental or purchase (at insurer's option) of durable medical equipment required for therapeutic use, including repairs and necessary maintenance of purchased equipment, not otherwise provided for under a manufacturer's warranty or purchase agreement.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.7