| Inpatient Care* |
|
|
Acute Hospital Care
(elective admissions for certain procedures require HNE’s prior approval) |
Yes
|
$500/admission
|
Skilled Care
(maximum of 100 days per calendar year) |
Yes
|
$500/admission
|
| Inpatient Rehabilitation
|
Yes
|
$500/admission
|
| Outpatient Preventive Care
|
|
|
| Adult Routine Exam
|
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) |
Yes
|
$25/visit
|
| Specialist Office Visits
|
Yes
|
$25/visit
|
| Second Opinions
|
Yes
|
$25/visit
|
| Hearing Tests in your PCP’s Office
|
Yes
|
$25/visit
|
| Diabetic-Related Items: |
|
|
| Outpatient Services |
Yes
|
$25/visit
|
| Laboratory/Radiological Services
|
Yes
|
$0
|
Durable Medical Equipment
(some items subject to $3,000 per calendar year maximum for DME; some items require HNE’s prior approval) |
Yes
|
20%
|
| Individual Diabetic Education |
No
|
$25/visit
|
| Group Diabetic Education |
No
|
$25/session
|
| Emergency Room Care
|
Yes
|
$75/visit
(Waived if admitted directly from ER) |
Diagnostic Testing
(some services may be subject to the Outpatient Surgical Services and Procedures Copayment) |
|
|
| In a Doctor’s office
|
Yes
|
$25 or $250/visit, based on specific procedure
|
| In all Other Settings
|
Yes
|
$0 or $250/admission, based on specific procedure
|
| Screening Colonoscopy
|
Yes
|
$0 (office visit copayment may apply if done in a doctor’s office) |
| Laboratory Services |
Yes
|
$0
|
Radiological Services: Ultrasound, X-rays, Nuclear Cardiology, Mammograms
(after first Mammogram in each calendar year) |
Yes
|
$0
|
Diagnostic Imaging: CT Scans, MRIs, MRAs, PET Scans
(requires prior approval) |
Yes
|
$0
|
Outpatient Short-Term Rehabilitation Services
(two months or 25 visits, whichever is greater, per condition per Calendar Year for physical or occupational therapy) |
Yes
|
$25/visit/treatment type
|
Day Rehabilitation Program
(limited to 15 full day or ½ 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.) |
Yes
|
$25/visit
|
Outpatient Surgical Services and Procedures
(some services require HNE’s prior approval): |
|
|
| In a Doctor’s office
|
Yes
|
$25 or $250/visit, based on specific surgical procedure
|
| All Other Settings
|
Yes
|
$0 or $250/admission, based on specific surgical procedure
|
| Allergy Testing and Treatment
|
Yes
|
$25/visit
|
| Allergy Injection only
|
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 requireHNE’s prior approval.) |
|
Some Assisted Reproductive services consist of outpatient surgery procedures; certain surgical procedures are subject to the outpatient surgical services and procedures copayment.
|
| Office Visit
|
Yes
|
$25/visit
|
| Laboratory Tests
|
Yes
|
$0
|
| Inpatient Care
|
Yes
|
$500/admission
|
| Outpatient Surgical Services and Procedures
|
Yes
|
$250/visit
|
| Maternity Care
|
|
|
Non-Routine Prenatal and Postpartum Care
(see also Routine Prenatal Care in Preventive Care section of this chart) |
Yes
|
$25/visit
|
Delivery/Hospital Care for Mother and Child
(For continued coverage, child must be enrolled within 31 days of date of birth) |
Yes
|
$500/admission
|
| Emergency Dental Services and Non-Dental Oral Surgery
|
|
|
Surgical Treatment of Non-Dental Conditions
(requires HNE’s prior approval) |
|
|
| In a Doctor’s office
|
Yes
|
$25/visit
|
| In a Hospital or Outpatient Surgical Facility
|
Yes
|
Inpatient: $500/admission Outpatient: $0 or $250/admission, based on specific surgical procedure |
| Emergency dental care in an Emergency Room
|
Yes
|
$75/visit
|
| Emergency dental care in a doctor’s or dentist’s office
|
Yes
|
$25/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. This does not count toward your Medical/Pharmacy deductible. 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) |
Yes
|
$0
|
Durable Medical Equipment, including ostomy supplies
(limited to $3,000 per calendar year; some items require HNE’s prior approval) |
Yes
|
20%
|
Prosthetic Limbs
(requires HNE’s prior approval) |
Yes
|
20%
|
| Ambulance and Chair Van Services |
Yes
|
$50/member/day
|
| Kidney Dialysis
|
Yes
|
$0
|
Nutritional Support
(requires HNE’s prior approval) |
Yes
|
$0
|
| Cardiac Rehabilitation
|
Yes
|
$25/visit
|
| Wigs (Scalp Hair Prostheses) for hair loss due to treatment of any form of cancer or leukemia. |
Yes
|
HNE pays up to a maximum of $350 per Calendar Year
|
Speech, Hearing, and Language Disorders
(outpatient treatment) |
Yes
|
$25/visit
|
Nutritional Counseling
(maximum of four visits per calendar year) |
Yes
|
$25/visit
|
| Non-Routine Immunizations by Your PCP
|
Yes
|
$25/visit
|
Human Organ Transplants and Bone Marrow Transplants
(requires HNE’s prior approval) |
Yes
|
$500/admission
|
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.) |
Yes
|
$500/admission
|
Outpatient services
(Care for some conditions may be limited to 24 visits per calendar year) |
Yes
|
$25/visit
|
| Substance Abuse Services
|
|
|
Inpatient services
(limited to 30 days per calendar year) |
Yes
|
$500/admission
|
For alcohol abuse
(limited to 30 days per calendar year) |
Yes
|
Outpatient services
(up to 20 visits per calendar year) |
Yes
|
$25/visit
|
| HNE covers outpatient treatment for alcoholism to the extent of $500 per calendar year
|
Yes
|
