| * Maximum responsibility per calendar year for Inpatient Care and Outpatient Surgical Services and Procedures Copayments |
$500 per individual / $1,000 per family; applies to services with a $150 or $250 copayment |
| Inpatient Care* |
|
Acute Hospital Care
(elective admissions for certain procedures require HNE’s prior approval )* |
$250/admission |
Skilled Nursing Facility*
(maximum of 100 days per calendar year ) |
$250/admission |
| Inpatient Rehabilitation |
$250/admission |
| 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/visit |
| Mammographic Exam |
$0 |
| Other Outpatient Care |
|
| Specialist Office Visits |
$15/visit |
| Second Opinions |
$15/visit |
| Diabetic-Related Items |
|
| Outpatient Services |
$15/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 |
$15/visit |
| Group Diabetic Education |
$15/session |
| Emergency Room Care |
$50/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 |
$15 or $150/visit, based on specific procedure |
| In All Other Settings |
$0 or $150/admission, based on specific surgical procedure |
| 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 ) |
$15/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 ) |
$15/visit |
Outpatient Surgical Services and Procedures*
(some services require HNE’s prior approval ): |
|
| In a Doctor’s Office |
$15 or $150/visit, based on specific surgical procedure |
| All Other Settings |
$0 or $150/admission, based on specific surgical procedure |
| Allergy Testing and Treatment |
$15/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 ) |
Some Assisted Reproductive services consist of outpatient surgery procedures; certain surgical procedures are subject to the outpatient surgical services and procedures copayment. |
| Outpatient Care |
$15/visit |
| Outpatient Surgical Services and Procedures |
$150/visit |
| Laboratory Tests |
$0 |
| Inpatient Care* |
$250/admission |
| Maternity Care |
|
| 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. ) |
$250/admission |
| Dental Services |
|
Surgical Treatment of Non-Dental Conditions
(requires HNE’s prior approval ) and Emergency Dental Care: |
|
| In a Doctor’s Office |
$15 or $150/visit, based on specific surgical procedure |
| At an Emergency Room |
$50/visit |
| In a Hospital or Outpatient Surgical Facility* |
Inpatient: $250/admissionOutpatient: $0 or $150/admission, based on specific surgical procedure |
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 requires HNE’s prior approval ) |
$25/member/day |
Reconstructive or Restorative Surgery*
(inpatient ) |
$250/admission |
| Kidney Dialysis |
$0 |
Human Organ Transplants and Bone Marrow Transplants*
(requires HNE’s prior approval ) |
$250/admission |
Nutritional Support
(requires HNE’s prior approval ) |
$0 |
| Cardiac Rehabilitation |
$15/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 |
$15/visit |
Nutritional Counseling
(maximum of four visits per calendar year ) |
$15/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. ) |
$250/admission |
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 ) |
$250/admission |
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 |
|
