Health New England Medicare Basic No Rx (HMO)

This is a high level overview of premium and benefit information for this plan. Health New England Medicare Basic No Rx (HMO) does NOT cover Medicare Part D prescription drugs. This plan does cover Medicare Part B prescription drugs.1


Monthly Plan Premium 

   

 $38

Medical Out-of-Pocket Maximum

   

 $4,900

Office Visits ($0 annual preventive exam)

   

 $30

Specialist Office Visits

   

 $40

Inpatient Hospital

   

 $275 per day for days 1-5, 
 
per admission.
 No maximum for inpatient.
           

Outpatient Surgery

   

 $4501

Skilled Nursing Facility (SNF)

   

Days 1-20: $0 copay per day1
Days 21-50: $120 copay per day 1
Days 51-100: $0 copay per day 1

World Wide Emergency Room (ER)

   

 $80

Ambulance

   

 $1501

Outpatient Rehabilitation (PA after visit 25)2

   

 $402

High Cost Imaging 

   

 $2251


Lab work/X-rays  

   

 $0 Labs
 $20 X-Rays

Durable Medical Equipment/Prosthetics

   

 20% coinsurance1





 
Additional Benefits

           

   

 

Preventive Hearing Exam3           

   

 $40

Hearing Aid Benefit - TruHearing®4
   

 $699 copay per aid Flyte Advanced
 $999 copay per aid Flyte Premium

Preventive Vision Exam     

   

 $0

Vision Eyewear Allowance3 

   

 $100 every two years

Dental Services Allowance

   

 $150 per year

Fitness, Weight Watchers®, Acupuncture

and Over-the-Counter Items Allowance3            

   

 $150 per year

Wig Allowance3 (if on chemotherapy) 

   

$350 per year    

       

1Some services require prior authorization (PA). Our network providers know what we cover under your benefit plan. They also know what requires
prior authorization and will request approval from Health New England on your behalf. For a complete list of services that require prior authorization,
refer to the summary of benefits.

2PA after visit 25 or if services are rendered in a SNF as an outpatient benefit when member is a resident of the SNF.

3Health New England additional benefits include allowances that must be used within the one or two calendar year period, as well as other additional benefits.
Refer to the Summary of Benefits or call Member Services if you have questions about what items and services are covered.

4You must see a TruHearing™ provider to use this benefit. Other providers are available in our network. Please note, hearing aids purchased through other providers are not covered.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/ co-insurance may change on January 1 of each year.

You must continue to pay your Medicare Part B premium.


H8578_2018_049 approved
last updated 9/30/17