Return to all 2020 plans

2020 Medicare Basic (HMO) No Rx

Jump to:

Additional Benefits   Plan Documents

Plan Overview

Monthly Premium $0
Medical Out-of-Pocket Maximum $4,900 
Office Visits ($0 annual preventive exam) $25 
Specialist Office Visits $40 
Inpatient Hospital $275 per day for days 1-5, per admission
Inpatient Hospital Maximum (per calendar year) No Maximum
Outpatient Surgery 1 $400
Skilled Nursing Facility (SNF) 1 Days 1–20: $0 copay per day
Days 21–50: $120 copay per day
Days 51–100: $0 copay per day
Teladoc Virtual Doctor Visits 7 $25
Urgent Care $50
World Wide Emergency Room (ER) $90
Ambulance 1 $150
Outpatient Rehabilitation (PA after 25 visits) 2 $40
High Cost Imaging 1 $225
Lab Work / X-rays $0 Labs / $20 X-rays
Durable Medical Equipment and Prosthetics 1 20% coinsurance

Additional Benefits

Preventive Hearing Exam 3 $40
Hearing Aid Benefit - TruHearing ®4 $699 copay per aid for Advanced Aids
$999 copay per aid Premium Aids
Preventive Vision Exam - EyeMed ® 3✝ $0
Vision Eyewear Allowance - EyeMed ® 3✝ $100 every two years
Dental Services Allowance 3 $250 per year
Fitness Center / Weight Watcher ® / Safety Items /
Over-the-Counter Allowance / Acupuncture /
Activity Tracker 3
$150 per year
Wig Allowance (if on chemotherapy) 3 $350 per year

Plan Documents


per month

Enroll Online Now

Or enroll over the phone by calling (855) 599-0465
TTY: 711

See all enrollment options

Have a Question?
Contact Us
Join an Info Session to learn more about your Medicare options Find a Session
Prefer printed materials? Order Materials

Helpful Links:

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.

2Prior authorization 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. Please note, hearing aids purchased through other providers are not covered. Other providers are available in our network.

5Mail-order: During the coverage gap stage, for the Health New England Premium (HMO) plan, preferred generics are covered at $8 for a three month supply. Non-preferred generics are covered at 25%, and Preferred and Non- Preferred Drugs are covered at 25% of the price or the Health New England negotiated price, whichever is lower. For the Plus (HMO) plan, the Value (HMO) plan and Select (HMO-POS) plan, standard coverage gap cost-sharing applies. During the catastrophic coverage stage, standard catastrophic coverage applies for all plans.

For questions related to Prescription Drug coverage, call (800) 393-0395, 24 hours a day, 7 days a week. TTY users should call 711.

6Licensed health insurance sales representative

7You must use Teladoc® service to receive this benefit.

8Out-of-network/non-contracted providers are under no obligation to treat Health New England Medicare Advantage members, except in emergency situations. Please call our Member Services number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

You must use an EyeMed® provider.

PA Members of the Health New England Medicare Select (HMO-POS) plan who choose to get these services out-of-network are responsible for getting prior authorization from Health New England. Please tell your out-of-network provider that prior authorization is required. The provider may be willing to contact Health New England Member Services for you to get prior authorization. Call Member Services to confirm prior authorization. For a complete list of services that require prior authorization, refer to the Summary of Benefits.

Health New England complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATTENTION: If you speak any language other than English, language assistance services, free of charge, are available to you. Call (413) 787-0010 or TTY 711. Health New England cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (413) 787-0010 o TTY 711. Health New England cumpre as leis de direitos civis federais aplicáveis e não exerce discriminação com base na raça, cor, nacionalidade, idade, deficiência ou sexo. ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (413) 787-0010 ou TTY 711. 

Last Updated 10/1/2019