Non-Group Plans
HMO and POS Options for the Uninsured
CDPHP Non-Group Plans were designed for individuals and families who don’t have group coverage but want to purchase health care coverage on a direct-pay basis.
Choose from an HMO plan with services delivered through the CDPHP network, and a point-of-service (POS) option that allows you to see doctors outside the CDPHP network.
Non-Group Rates & Application Form
Applications and the first month’s premium are due by the 5th of the month to be eligible on the 1st of the following month. Existing CDPHP members who are converting from a group plan have 45 days to convert to a non-group plan from the date of termination of the group policy with no break in coverage. Applications will be accepted in the CDPHP lobby Monday through Friday, 8:30 am to 4:30 pm
For more information, call CDPHP at (518) 641-3700. See also Government Programs.
Non-Group HMO Option Benefit Summary
|
Benefit
|
Description |
|---|
|
Physician Visits |
$15 copayment |
|
Inpatient Hospital Stays
|
$500 copayment |
|
Surgical Copayment |
Lesser of $200 or 20% |
|
Outpatient Mental Health Visits |
10% coinsurance |
|
Prescription Drug Coverage |
- $100 deductible per calendar year per individual or $300 combined for all family members.
- After deductible is met, each 34-day supply of covered generic drugs is subject to a $5 copay; 34-day supply of covered brand name drugs is subject to a $10 copay
|
|
Diagnostic and Treatment |
$15 copayment |
|
Diabetic Equipment and Supplies |
$15 copayment |
|
Emergency Room |
$50 copayment |
|
Routine Adult Physicals |
$15 copayment |
|
Routine Gynecological Visits |
$15 copayment |
|
Specialist Visits (by referral from PCP) |
$15 copayment |
|
Outpatient Surgery |
$75 copayment |
|
Private Duty Nursing |
Benefit capped at $5,000 per member per calendar year; $10,000 per lifetime |
|
Out-of-Pocket Maximum Per Calendar Year |
$1,500 per individual; $3,000 combined for all family members. |
Non-Group POS Option Benefit Summary
|
Benefit |
In-Network |
Out-of-Network |
|---|
|
Deductible Per Calendar Year |
N/A |
$1,000 individual
$2,000 family (combined) |
|
Coinsurance |
N/A except for outpatient mental health |
20% applicable to all services unless otherwise noted |
|
Physician Visits |
$10 copayment |
Subject to deductible and coinsurance |
|
Outpatient Mental Health |
10% coinsurance |
10% coinsurance |
|
Inpatient Hospital Stays
|
Covered in full |
Subject to deductible and coinsurance |
|
Prescription Drug Coverage |
- $100 deductible per calendar year per individual or $300 combined for all family members.
- After deductible is met, each 34-day supply of covered generic drugs is subject to a $5 copay; 34-day supply of covered brand name drugs is subject to a $10 copay
- Participating pharmacies only
|
Not covered |
|
Diagnostic and Treatment |
$10 copayment |
Subject to deductible and coinsurance |
|
Diabetic Equipment and Supplies |
$10 copayment |
Subject to deductible and coinsurance |
|
Emergency Room |
$35 copayment |
$35 copayment |
|
Specialist Visits |
$10 copayment |
Subject to deductible and coinsurance |
|
Outpatient Surgery |
$10 copayment |
Subject to deductible and coinsurance |
|
Private Duty Nursing |
Benefit capped at $5,000 per member per calendar year; $10,000 per lifetime |
Benefit capped at $5,000 per member per calendar year; $10,000 per lifetime |
|
Out-of-Pocket Maximum Per Calendar Year |
N/A |
$3,000 per individual; $5,000 combined for all family members. |
|
Lifetime Benefit Maximum |
N/A |
$500,000 |
Out-of-Network Benefits: In addition to applicable copayment, deductible, and/or coinsurance, a 10% penalty will be imposed for failure to comply with precertification requirements and notification of emergency services received outside the service area.
This summary does not detail all benefits, limitations, or exclusions. All non-emergency services must be provided by a CDPHP participating provider unless otherwise prior approved by CDPHP.