This chart provides a summary of key services offered by your HNE plan. Consult your member agreement for a full description of your plan’s benefits and provisions. If any terms in this summary differ from those in your member greement, the terms of the member agreement apply. 

BENEFIT	Deductible Applies	HNE EssentialMax Copayment
Inpatient Care
Acute Hospital Care (elective admissions for certain procedures require HNE’s prior approval)
Physician charges	No	$0
Facility charges	Yes	$0
Skilled Nursing Facility (maximum of 100 days per calendar year)
Physician charges	No	$0
Facility charges	Yes	$0
Inpatient Rehabilitation
Physician charges	No	$0
Facility charges	Yes	$0
Outpatient Preventive Care
Adult Routine Exams	No	$0/visit
Routine Prenatal Care	No	$0/visit
Well Child Care	No	$0/visit
Child and Adult Routine Immunizations	No	$0/visit
Cancer Screening
Breast Cancer (1 Mammogram per calendar year)	No	$0
Cervical Cancer (Pap smear)	No	$0
Colorectal Cancer (Fecal Occult Blood Test)	No	$0
Prostate Cancer (PSA Test)	No	$0
Heart and Vascular Diseases Screening
Lipid Disorders	No	$0
Infectious Diseases Screening
Chlamydial Infection	No	$0
Human Immunodeficiency Virus (HIV) Infection	No	$0
Musculoskeletal Disorders Screening
Osteoporosis	No	$0
Obstetric and Gynecological Conditions Screening
Neural Tube Defects	No	$0
Rh Incompatibility	No	$0
Rubella	No	$0
Ultrasonography in Pregnancy (one per pregnancy)	No	$0
Pediatric Conditions Screening
Lead Levels in Childhood and Pregnancy	No	$0
Phenylketonuria	No	$0
Routine Eye Exams (one per calendar year)	No	$0/visit
Annual Gynecological Exams	No	$0/visit
Other Outpatient Care
PCP Office Visits (non-routine)	No	$20/visit
Specialist Office Visits	No	$40/visit
Second Opinions	No	$40/visit
Hearing Tests in Your PCP’s Office
In Your PCP’s Office	No	$20/visit
In a Specialist’s Office	No	$40/visit
In a Facility	Yes	$0
Diabetic-Related Items:
Outpatient Services
In a Doctor’s Office	No	$40/visit
In a Facility	Yes	$40/visit
Laboratory Services	No	$0
Radiological Services
In a Doctor’s Office	No	$0
In a Facility	Yes	$0
Durable Medical Equipment (some items subject to $3,000 per calendar year maximum for DME; some items require HNE’s prior approval)	No	20%
Individual Diabetic Education	No	$40/visit
Group Diabetic Education	No	$20/session
Emergency Room Care	Yes	$100/visit (Waived if admitted directly from ER)
Diagnostic Testing
In a Doctor’s office	No	$40
In all Other Settings
Physician Charges	No	$0
Facility Charges	Yes	$0
Screening Colonoscopy
Physician Charges	No	$0
Facility Charges	Yes	$0
Laboratory Services	No	$0
Radiological Services: Ultrasound, X-rays, Nuclear Cardiology, Mammograms (after first Mammogram in each calendar year)
In a Doctor’s Office	No	$0
In a Facility	Yes	$0
Diagnostic Imaging: CT Scans, MRIs, MRAs, PET Scans (requires prior approval)	Yes	$100
Outpatient Short-Term Rehabilitation Services (two months or 25 visits, whichever is greater, per condition per calendar year for physical or occupational therapy)
In a Doctor’s Office	No	$40/visit/ treatment type
In a Facility	Yes	$40/visit/ treatment type
Day Rehabilitation Program (limited to 15 full day or half day sessions per condition per lifetime)	Yes	$25/day or half day
Early Intervention Services (limited to $5,200 per child per calendar year with a lifetime maximum of $15,600. Covered for children from birth to age 3.)	No	$40/visit
Outpatient Surgical Services and Procedures (some services require HNE’s prior approval):
In a Doctor’s office	No	$40visit
All Other Settings
Physician’s Charges	No	$0
Facility Charges	Yes	$0
Allergy Testing and Treatment
In a Doctor’s Office	No	$40visit
In a Facility	Yes	$40visit
Allergy Injection Only
In a Doctor’s Office	No	$0
In a Facility	Yes	$0
Family Planning Services and Infertility Treatment (Some services are covered only for Massachusetts residents and for Connecticut residents under the age of 40; some services require HNE’s prior approval.)
Office Visit	No	$40/visit
Laboratory Tests	No	$0
Inpatient Care
Physician Charges	No	$0
Facility Charges	Yes	$0
Outpatient Surgical Services and Procedures
In a Doctor’s office	No	$40/visit
All Other Settings
Physician’s Charges	No	$0
Facility Charges	Yes	$0
Maternity Care
Non-Routine Prenatal and Postpartum Care (see also Routine Prenatal Care in Preventive Care section of this chart)	No	$40/visit
Delivery/Hospital Care for Mother and Child (For continued coverage, child must be enrolled within 31 days of date of birth)
Physician Charges	No	$0
Facility Charges	Yes	$0
Emergency Dental Services and Non-Dental Oral Surgery
Surgical Treatment of Non-Dental Conditions (requires HNE’s prior approval)
In a Doctor’s office	No	$40/visit
In a Hospital or Outpatient Surgical Facility
Physician Charges	No	$0
Facility Charges	Yes	$0
Emergency dental care in an Emergency Room	Yes	$100/visit
Emergency dental care in a doctor’s or dentist’s office	No	$40/visit
Children’s Routine Dental Services
Routine dental services for children under the age of 12. (A separate $25 per child per calendar year deductible applies only to services from Out-of-Plan dentists. Out-of-Plan dentists may also bill you for the difference between their charge and HNE’s contracted dental network Maximum Allowable Fee.)	No	$0
Other Services
Home Health Care (requires HNE’s prior approval)	Yes	$0
Hospice Services (requires HNE’s prior approval)	No	$0
Durable Medical Equipment, including ostomy supplies (limited to $3,000 per calendar year, some items require HNE’s prior approval)	No	20%
Prosthetic Limbs (requires HNE’s prior approval)	No	20%
Ambulance and Chair Van Services	Yes	$100/member/day
Kidney Dialysis	No	$0
Nutritional Support (requires HNE’s prior approval)	No	$0
Cardiac Rehabilitation
Physician Charges	No	$40/visit
Facility Charges	Yes
Wigs (Scalp Hair Prostheses) for hair loss due to treatment of any form of cancer or leukemia.	No	HNE pays up to a maximum of $350 per calendar year
Speech, Hearing, and Language Disorders (outpatient treatment)
In a Doctor’s Office	No	$40/visit
In a Facility	Yes	$40/visit
Nutritional Counseling (maximum of four visits per calendar year)	No	$40/visit
Non-Routine Immunizations by Your PCP	No	$20/visit
Human Organ Transplants and Bone Marrow Transplants  (requires HNE’s prior approval)
Inpatient Physician Charges	No	$0
Inpatient Facility Charges	Yes	$0
Mental Health and Substance Abuse Services (requires HNE’s prior approval)
Mental Health Services:
Inpatient services (Care for some conditions may be limited to 60 days per calendar year.)
Physician Charges	No	$0
Facility Charges	Yes	$0
Outpatient services (Care for some conditions may be limited to 24 visits per calendar year)
In a Doctor’s Office	No	$20/visit
In a Facility	No	$20/visit
Substance Abuse Services
Inpatient services (limited to 30 days per calendar year)
Physician Charges	No	$0
Facility Charges	Yes	$0
For alcohol abuse (limited to 30 days per calendar year)
Outpatient services (up to 20 visits per calendar year)
Visits 1-8 in a Doctor’s Office	No	$20/visit
Visits 9-20 in a Doctor’s Office	No	$40/visit
Visits 1-8 in a Facility	Yes	$20/visit
Visits 9-20 in a Facility	Yes	$40/visit
HNE covers outpatient treatment for alcoholism to the extent of $500 per calendar year