Inpatient Care
|
|
Acute Hospital Care
(elective admissions for certain procedures require HNE’s prior approval) |
$100
|
Skilled Nursing Facility
(maximum of 100 days per calendar year) |
$100
|
| Inpatient Rehabilitation |
$100
|
Outpatient Preventive Care
|
|
| Office Visits |
$15/visit
|
| Routine Physical Exams |
$0
|
| Well Child Care |
$0
|
| Routine Eye Exams (one per calendar year) |
$0
|
| Hearing Tests in your PCP’s office |
$15/visit
|
| Annual Gynecological Exam |
$0
|
| Mammographic Exam |
$0
|
Other Outpatient Care
|
|
Specialist Office Visits
|
$25/visit
|
Second Opinions
|
$25/visit
|
Diabetic-Related Items
|
|
Outpatient Services
|
$25/visit
|
Laboratory/Radiological Service
|
$0
|
Durable Medical Equipment
(some items subject to $3,000 per calendar year maximum for DME; some items require HNE’s prior approval)
|
20% copayment
|
| Individual Diabetic Education |
$25/visit
|
| Group Diabetic Education |
$15/session
|
Emergency Room Care
|
$75/visit (waived if admitted directly from ER)
|
Diagnostic Testing
|
|
In a Doctor’s office
|
$25/visit
|
In All Other Settings
|
$100
|
Screening Colonoscopy
|
$0 (office visit copayment may
apply if done in a doctor’s office) |
Laboratory Services
|
$0
|
Radiological Services: Ultrasound, X-rays, Nuclear Cardiology
|
$0
|
Diagnostic Imaging: CT Scans, MRIs, MRAs, Pet Scans
(requires prior approval) |
$0
|
Outpatient Short-Term Rehabilitation Services
(limited to two months or 25 visits, whichever is greater, per condition per calendar year for physical and occupational therapy) |
$25/visit/treatment type
|
Day Rehabilitation Program
(limited to 15 full day or half day sessions per condition per lifetime) |
$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 three) |
$25/visit
|
Outpatient Surgical Services and Procedures
(some services require HNE’s prior approval) |
|
In a Doctor’s Office
|
$25/visit
|
All Other Settings
|
$100
|
Allergy Testing and Treatment
|
$25/visit; $0 for injection
|
Family Planning Services and Infertility Treatment
(some infertility treatments are covered only for Massachusetts residents and for Connecticut residents under the age of 40; some treatments require HNE’s prior approval) |
|
Outpatient Care
|
$25/visit
|
Laboratory Tests
|
$0
|
Inpatient Care
|
$100
|
Maternity Care
|
|
Routine Prenatal and Postpartum Care
|
$0
|
Delivery/Hospital Care for Mother and Child
(Coverage for child limited to routine newborn nursery charges. For continued coverage, child must be enrolled within 31 days of date of birth.) |
$100
|
Dental Services
|
|
Surgical Treatment of Non-Dental Conditions (requires HNE’s prior approval) and Emergency Dental Care:
|
|
In a Doctor’s Office
|
$25/visit
|
At an Emergency Room
|
$75/visit
|
In a Hospital or Outpatient Surgical Facility
|
$100
|
| Children’s Preventive Dental (limited to preventive services for children under age 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. |
$0
|
Other Services
|
|
Home Health Care
(requires HNE’s prior approval) |
$0
|
Hospice Services
(requires HNE’s prior approval) |
$0
|
Durable Medical Equipment
(some items require HNE’s prior approval; benefit maximum $3,000 per calendar year) |
20%
|
Prosthetic Limbs
(requires HNE’s prior approval) |
20%
|
Ambulance and Chair Van Services
(non-emergency transportation require HNE’s prior approval) |
$25/member/day
|
Reconstructive or Restorative Surgery
|
$100
|
Kidney Dialysis
|
$0
|
Human Organ Transplants and Bone Marrow Transplants
(requires HNE’s prior approval) |
$100
|
Nutritional Support
(requires HNE’s prior approval) |
$0
|
Cardiac Rehabilitation
|
$25/visit
|
Scalp Hair Prostheses (Wigs) for hair loss due to treatment of any form of cancer or leukemia
|
HNE pays up to $350 per calendar year |
Speech, Hearing, and Language Disorders
|
$25/visit
|
Nutritional Counseling
(maximum of four visits per calendar year) |
$25/visit
|
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.)
|
$100
|
Outpatient Services
(Care for some conditions may be limited to 24 visits per calendar year.)
|
$15/visit
|
Substance Abuse Services:
|
|
Inpatient Services
(limited to 30 days per calendar year) |
$100
|
For alcohol abuse
(limited to 30 days per calendar year)
|
|
Outpatient Services
(limited to 20 visits per calendar year) |
|
For visits 1 – 8
|
$10/visit
|
For visits 9 – 20
|
$20/visit
|
HNE covers outpatient treatment for alcoholism to the extent of $500 per calendar year
|
|
