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Small Groups: Basic HMO

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Plans	Basic HMO
Plans	HNE Wise^Plus HDHP M HMO	HNE Wise^Max HDHP H HMO	HNE Essential¹⁵⁰⁰	HNE Essential¹⁰⁰⁰	HNE Essential⁵⁰⁰
Up-front deductible	$2,000 per individual $4,000 per family per policy OR calendar year	$2,000 per individual $4,000 per family per policy OR calendar year	$1,500 per individual $3,000 per family per policy OR calendar year	$1,000 per individual $2,000 per family per policy OR calendar year	$500 per individual $1,000 per family per policy OR calendar year
Doctor’s Office	$0 Preventive Services $25 after deductible for all other office visits	$0 Preventive Services $0 after deductible for all other office visits	$0 Preventive Services $20 All other office visits	$0 Preventive Services $20 All other office visits	$0 Preventive Services $20 All other office visits
Emergency (waived if admitted directly from ER)	$75 after deductible	$0 after deductible	$100 per visit	$100 per visit	$100 per visit
Diagnostic Imaging: CT Scans, MRI, PET Scans	$0 after deductible	$0 after deductible	$0 after deductible	$0 after deductible	$0 after deductible
Outpatient Surgical	$250 after deductible	$0 after deductible	$0 after deductible	$0 after deductible	$0 after deductible
Hospital Stay	$500 after deductible	$0 after deductible	$0 after deductible	$0 after deductible	$0 after deductible
Out-of-Pocket Maximum	$5,000 per individual $10,000 per family	$5,000 per individual $10,000 per family	$3,000 per individual $6,000 per family	$2,000 per individual $4,000 per family	$2,000 per individual $4,000 per family
Out-of-Pocket Maximum Includes:	Deductible and copayments	Deductible and copayments	Deductible and services with a copayment of $100 or greater	Deductible and services with a copayment of $100 or greater	Deductible and services with a copayment of $100 or greater

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