N.Y. Comp. Codes R. & Regs. tit. 11 § 52.6

Current through Register Vol. 46, No. 50, December 11, 2024

Section 52.6 - Basic medical insurance

Basic medical insurance is an insurance policy which provides coverage for services rendered by a physician or, in the case of article 43 corporations, a participating physician, to each covered person for sickness or injury for:

(a) Surgical services, consisting of operating and cutting procedures for the treatment of a sickness or injury, and endoscopic procedures, including any pre- and post-operative care usually rendered in connection with such operation or procedure, in an amount:

(1) not less than 80 percent of the reasonable charges; or

(2) if specified in dollar amounts, a fee schedule providing amounts for any procedure at least equal to those provided for in a fee schedule with a maximum of $2,600 based on the relative values contained in the State of New York Certified Surgical Fee Schedule, or an equivalent fee schedule approved by the superintendent.

(b) Anesthetic services, consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical service rendered by a physician, other than the physician performing the surgical service or his assistant, in an amount not less than 80 percent of the reasonable charges or 15 percent of the benefit provided in paragraph (a)(2) of this section.

(c) In-hospital medical services, consisting of physician services rendered to a person who is a bed patient in a hospital for treatment of sickness or injury other than that for which surgical or pregnancy care is required, in an amount not less than 80 percent of the reasonable charges or $25 per day for not less than 60 days.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.6