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.
