Our Limited Benefit Health Program (LBHP) for New York State is designed to provide businesses with affordable accident and sickness coverage for employees who are not covered by traditional benefit programs and employees who want to supplement other insurance coverage.
The following information is specific to NEW YORK STATE. You can view general state information for Limited Benefit Health Programs by clicking here.
Flex Shield Access Benefit
| Print Coverage/Rate Sheet | ||||
| Benefit | Bronze | Silver | Gold | Frequency Limits |
| Physicians Office Visits |
$50 per visit | $75 per visit | $100 per visit | 3 per insured/year; 6 per family/year |
| Diagnostic X-Ray and Lab Tests |
$50 per visit | $75 per visit | $100 per test | 3 per insured/year; 6 per family/year |
| Health Screening | $50 per visit | $75 per test | $100 per test | Up to 3 tests per insured/year |
| Well Child Care | $50 per visit | $50 per visit | $50 per visit | Up to 6 visits/year |
| Emergency Room | $50 per visit | $100 per visit | $150 per visit | Up to 4 visits/year |
| Hospital Admission | $250 per admission | $400 per admission | $750 per admission | |
| Daily Hospital Confinement | $250 per day | $400 per day | $750 per day | Up to first 30 days of confinement |
| Intensive Care Unit | $250 per day | $400 per day | $750 per day | Up to first 30 days of confinement |
| Surgery | 25% of amount in schedule of operations | 50% of amount in schedule of operations | 50% of amount in schedule of operations | |
| Anesthesia | 25% of amount in schedule of operations | 50% of amount in schedule of operations | 50% of amount in schedule of operations | |
| Prescription Drug | $5 per script | Up to 5 scripts per year | ||
Access Specific Benefits
| Benefits | Covered by all Plans | Frequency Limits |
| Ambulance | $50 | Up to 2/year |
| Transportation (Ground & Air) | $100 | Up to 3 round trips per year |
| Lodging |
$25 per day | 2 days/occurrence; $3,000 Calendar Yr. Max |
| Diabetes Supplies, Equipment &Self Management | $100 | 1/year |
| Mammogram Screening | $100 per screening | Counts towards number of annual tests |
| Cervical Cytology Screening | $100 per screening | Counts towards number of annual tests |
| Prostate Cancer Screening | $100 per screening | Counts towards number of annual tests |
| Second Surgical Opinion | $100 per visit | 2 visits/year |
| Prosthesis |
$250 per covered accident | |
| Second Medical Option for Cancer Diagnosis | $100 per visit | |
| End of Life Care | $25 per day | 60 days |
| Home Health Care | $25 per visit | 40 visits |
| Outpatient Chemical Abuse & Dependence Treatment | $25 per visit | Up to 60 visits per year |
| Outpatient Mental, Nervous or Emotional Disorders | $25 per visit | Up to 20 visits/yr. for mental health |
| Ambulatory Surgical Center | $50 per visit | Up to 4 visits/year |
| Accidental Death | $5,000 |
Flex Shield Enhanced Benefits
| Print Coverage/Rate Sheet | ||||
| Benefits | Bronze | Silver | Gold | Frequency Limits |
| Physicians Office Visits |
$50 per visit | $100 per visit | $150 per visit | 3 per insured/year; 6 per family/year |
| Diagnostic X-Ray/Lab Tests | $50 per test | $100 per test | $250 per test | 3 per insured/year; 6 per family/year |
| Health Screening | $50 per test | $150 per test | $250 per test | Up to 3 tests per insured/year |
| Well Child Care | $50 per visit | $100 per visit | $250 per visit | Up to 6 visits/year |
| Emergency Room | $50 per visit | $150 per visit | $250 per visit | Up to 4 visits/year |
| Hospital Admission | $250 per admission | $750 per admission | $1,000 per admission | |
| Daily HospitalConfinement | $200 per day | $400 per day | $750 per day | Up to first 30 days of confinement |
| Intensive Care Unit | $250 per day | $750 per day | $1,000 per day | Up to first 30 days of confinement |
| Surgery | 100% of amount in schedule of operations |
250% of amount in schedule of operations |
500% of amount in schedule of operations |
|
| Anesthesia | 25% of amount | 50% of amount in schedule of operations |
50% of amount in schedule of operations |
|
| Prescription Drug | $5 per script | $10 per script | $15 per script | Up to 5 scripts/year |
Specific Enhanced Benefits
| Benefits | Bronze | Silver | Gold | Frequency Limits |
| Sickness & Non-Occupational Accident Disability Income | N/A | $250 p/wk; 7 day elimination period; 13 week duration | $400 p/wk; 7-day elimination period; 26 week duration | |
| Outpatient Ambulatory Care | N/A | $150 per visit | $250 per visit | Up to 4/year |
| Ground Ambulance Benefit | $150 per use | $250 per use | $250 per use | Up to 4/year |
| Transportation Benefit | $100 per trip | Air – $500; Other $250 | Air – $1,000; Other $250 | Up to 3 round trips/year; $3,000 annual max |
| Lodging | $25/day; 2 day max./occurrence | $100/day; 10 day max./occurrence | $100/day; 10 day max./occurrence | $3,000 annual max./occurrence |
| Diabetes Supplies, Equipment and Self-Management | $100 | $250 | $1,000 | 1/year |
| Mammogram Screening |
$100 per screening | Counts towards number of annual tests | ||
| Cervical Cytology Screening | $100 per screening | Counts towards number of annual tests | ||
| Prostate Cancer Screening |
$100 per screening | Counts towards number of annual tests | ||
| Second Surgical Opinion |
$100 per visit | 2 visits/year | ||
| Prosthesis |
$250 per covered accident | |||
| Second Medical Option for Cancer Diagnosis | $100 per visit | |||
| End of Life Care | $25 per day | 60 days | ||
| Home Health Care | $25 per visit | 40 visits | ||
| Outpatient Chemical Abuse and Dependence Treatment | $25 per visit | Up to 60 visits/year | ||
| Outpatient Mental, Nervous or Emotional Disorders | $25 per visit | Up to 20 visits/year for Mental Health | ||
| Ambulatory Surgery Center |
$50 per visit | Up to 4 visits/year | ||
| Accidental Death | $5,000 | $5,000 | ||
Beech Street Network Discount Rates
Participating Beech Street Network Providers offer LBHP participants up to a 40% discount on their standard rates or fees.
Example:
- Standard Doctor’s visit rate: $100
- 40% Beech Street Discounted rate :$60
- LBHP Plan Benefit Paid: $50
- Out of Pocket expense for LBHP Participant: $10
For more information, please visit Beech Street’s Network Services page.
Monthly Rates (NY Only)
| Rate Indications (Monthly Rates) | Print Coverage/Rate Sheet |
| Voluntary | |||
| 100% Voluntary Rates | Bronze | Silver | Gold |
| Employee Only | $81 | $114 | $160 |
| Employee + Spouse | 158 | $227 | $319 |
| Employee + Children | $174 | $245 | $344 |
| Employee + Family | $245 | $245 | $488 |
| Employer Contribution | |||
| 25-49% Employer Contribution | Bronze | Silver | Gold |
| Employee Only | $74 | $105 | $147 |
| Employee + Spouse | $145 | $208 | $292 |
| Employee + Children | $160 | $225 | $448 |
| Employee + Family | $224 | $225 | $448 |
| 50-99% Employer Contribution | Bronze | Silver | Gold |
| Employee Only | $71 | $100 | $140 |
| Employee + Spouse | $139 | $198 | $279 |
| Employee + Children | $153 | $214 | $301 |
| Employee + Family | $214 | $214 | $427 |
| 100% Employer Contribution | Bronze | Silver | Gold |
| Employee Only | $67 | $95 | $133 |
| Employee + Spouse | $132 | $189 | $266 |
| Employee + Children | $145 | $204 | $287 |
| Employee + Family | $204 | $204 | $407 |
Flex Shield Enchanced Rates (NY Only) |
|||
| Rate Indications (Monthly Rates) | Print Coverage/Rate Sheet | ||
| Voluntary | |||
| 100% Voluntary Rates | Bronze | Silver | Gold |
| Employee Only | $81 | $175 | $370 |
| Employee + Spouse | $159 | $337 | $590 |
| Employee + Children | $175 | $379 | $640 |
| Employee + Family | $246 | $526 | $896 |
| Employer Contribution | |||
| 25-49% Employer Contribution | Bronze | Silver | Gold |
| Employee Only | $74 | $161 | $283 |
| Employee + Spouse | $146 | $309 | $541 |
| Employee + Children | $161 | $348 | $588 |
| Employee + Family | $226 | $483 | $823 |
| 50-99% Employer Contribution | Bronze | Silver | Gold |
| Employee Only | $71 | $147 | $258 |
| Employee + Spouse | $139 | $295 | $517 |
| Employee + Children | $161 | $348 | $588 |
| Employee + Family | $226 | $483 | $823 |
| 100% Employer Contribution | Bronze | Silver | Gold |
| Employee Only | $68 | $147 | $258 |
| Employee + Spouse | $133 | $282 | $493 |
| Employee + Children | $146 | $317 | $535 |
| Employee + Family | $205 | $439 | $749 |
Frequently Asked Questions (FAQ)
Q. As an employer, can I just pay only for a portion of my employee’s individual monthly premium even if they want to cover their spouse and/or family?
A. Yes, we can set up the premiums so that the Employer pays the Employed Enrollee coverage and the Employed Enrollee pays for spouse or dependent coverage.
Q. As an employer, can I adjust the amount I’m contributing to my employee’s premium either annually or based on length of service?
A. You can change your percentage of contribution to the plan on an annual basis at policy renewal but not during the term of the policy or per employee.
Q. The maximum for daily hospital confinement is $30K. A surgery and subsequent 3 day hospital confinement can often exceed $75K. Is there another plan that would cover the difference?
A. LBHP has a limit of $1,000 p/day for hospital confinement with a maximum of $30K. In order to receive the full $30K the patient would have to be in the hospital for 30 days at $1,000 p/day. There is coverage for surgery of up to $2,000 per scheduled amount as well. In this scenario benefits would be paid for up to $5,000 ($3,000 per hospital confinement at $1,000 p/day for 3 days plus up to $2,000 for surgery).
Q. If I am an enrollee in LBHP through my employer and have a comprehensive health plan through my employer as well, would LBHP still pay benefits in addition to my comprehensive plan?
A. Yes, LBHP would pay in addition to your comprehensive plan. For example if you go to the doctor through your comprehensive plan and pay a $25 co-pay for that visit, LBHP would pay $50 for that visit, so you would get your $25 co-pay back plus an additional $25.
Q. If I am an enrollee in LBHP through my employer, can I also open a Heath Savings Plan (HSA)?
A. An individual is eligible to have an HSA if they DO have a high-deductible health plan (HDHP) and they DO NOT have certain other kinds of coverages in addition to that HDHP.
Q. As an employer, what is the minimum group size for eligibility?
A. The program requires a minimum of 10 enrolled employees in order to be eligible. Employer organizations with less than 10 enrolled employees can still participate in the program as a participating organization in a Master Policy we’ve created, however, the employer must contribute at least 50% of the enrolled employee’s monthly premium in this circumstance.
In NY there is a requirement for a minimum of 10 enrolled employees. In addition, the organization MUST have at least 50 eligible employees to participate in LBHP. NY employers that do not meet the above requirements are ineligible for coverage and cannot participate in the Master Policy option.
E-mail your questions or call our Underwriting Department at 800-622-8272.
Please note: ISA’s Limited Benefit Health Program is written directly through ISA. Flex Shield is not traditional comprehensive health insurance and should not be considered a substitute for comprehensive insurance or major medical coverage. Benefits and coverages may vary by state.
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