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Summary of Benefits

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Summary Of Benefits: HNE PPO Compete

PPO SUMMARY OF BENEFIT CHART

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 agreement, the terms of the member agreement apply.

Benefits under the Plan are limited to a lifetime maximum of $2 million per person.
Please note: for Out-of-Plan services, you are also responsible for any Remaining Balances. A Remaining Balance is that portion of an Out-of-Plan Provider’s charge that is above HNE’s Maximum Allowable Fee.
Note about Prior Approval:
Some services require prior approval. These services are marked with * in the chart. In some cases, if you fail to ask for prior approval the service will not be covered at all. (See, for example, Infertility Treatment below.) In other cases, for example Acute Hospital Care at an Out-of-Plan facility, if you fail to ask for prior approval you may have a reduction of benefit up the amount indicated below. Remember that exclusions or limitations of this plan still apply, even if you ask for prior approval. For example, services that are not medically necessary are not covered, even if you ask for prior approval.

HNE PPO Compete	In-Plan Provider	Out-of-Plan Provider
Maximum responsibility per calendar year for copayments for Inpatient Care and Outpatient Surgical Services	$1,000 per individual $2,000 per family	Not applicable
Deductible per calendar year	Not applicable	$1,000 per individual† $2,000 per family
† Once any individual on a family plan has met the individual deductible, the plan will begin to pay benefits for that individual.
Coinsurance Maximum per calendar year	Not applicable	$2,000 per individual $4,000 per family
*Reduction of Benefit – applies to certain services if prior approval is required but not requested. This applies to items marked with this symbol: “”**	Not applicable	$500

Benefit	Your Copayment In-Plan Provider	Your Coinsurance and Coinsurance Out-of-Plan Provider
Inpatient Care* (elective admissions to Out-of-Plan facilities require Prior Approval)
Hospital Care*	$500/admission	20%
Skilled Nursing Facility* (maximum of 100 days per calendar year)	$500/admission	20%
Acute Inpatient Rehabilitation*	$500/admission	20%
Outpatient Preventive Care
Physician Office Visits	$20/visit	20%
Routine Physical Exams	$20/visit	20%
Well Child Care	$20/visit	20%
Routine Eye Exams (one per calendar year)	$20/visit	20%
Hearing Tests	$20/visit	20%
Annual Gynecological Exams	$20/visit	20%
Mammographic Exam	$0	20%
Other Outpatient Care
Specialist Office Visits	$20/visit	20%
Second Opinions	$20/visit	20%
Diabetic-Related Items:
Outpatient Services	$20/visit	20%
Laboratory/Radiological Services	$0	20%
Durable Medical Equipment* ($3,000 per Calendar Year limit applies to some items, some items require Prior Approval)	20%	20%
Prescription Drugs (some drugs require Prior Approval)	For Copayment & Coinsurance see the Prescription Drug Benefit chart.
Group Diabetic Education Series	$20/session	20%
Emergency Room Care (Copayment waived if admitted directly from ER)	$50/visit	$50/visit
Diagnostic Testing (some services are subject to the Outpatient Surgical Services and Procedures Copayment, see Outpatient Surgical Services and Procedures below)	$20/visit	20%
Screening Colonoscopy (office visit Copayment may apply if done in n In-Plan doctor’s office)	$0	20%
Laboratory Services	$0	20%
Radiological Services: Ultrasound, X-rays, Nuclear Cardiology, Mammograms	$0	20%
Diagnostic Imaging*: CT Scans, MRIs, MRAs, PET Scans (requires Prior Approval)	$0 (If Prior Approval is denied, Member is responsible for all costs.)	20% (Without Prior Approval, Member pays all costs.)
Outpatient Short-Term Rehabilitation Services (two months or 25 visits, whichever is greater, per condition per calendar year for physical or occupational therapy)	$20/visit per treatment type	20%
Day Rehabilitation Program	$25 per day or ½ day	20%
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.)	$20/visit	20%
Outpatient Surgical Services and Procedures* (some services require Prior Approval)	$250/admission NOTE: The Outpatient Surgical Services and Procedures Copayment is applied based on the type of service, not where it is performed. To find out if the Outpatient Surgical Services and Procedures Copayment applies to a specific procedure, please contact HNE Member Services.	20%
Allergy Testing and Treatment	$20/visit	20%
Allergy Injection only	$0	20%
Family Planning and Infertility Treatment* Some infertility services require Prior Approval. Some infertility treatments are covered only for Massachusetts residents and for Connecticut residents under the age of 40. Some Assisted Reproductive services consist of outpatient surgery procedures. If you receive one of these services, the Outpatient Surgical Services and Procedures Copayment may apply.
Family Planning Services	$20/visit	20%
Infertility Services*
Office Visits	$20/visit	20% (If Prior Approval not requested, Member pays all costs)
Outpatient Surgical Services and Procedures*	$250/admission	20% (If Prior Approval not requested, Member pays all costs)
Laboratory Tests	$0	20% (If Prior Approval not requested, Member pays all costs)
Inpatient Care* (Infertility Services)	$500/admission	20% (If Prior Approval not requested, Member pays all costs)
Maternity Care
Routine Prenatal and Postpartum Care (Note: Copayments apply to non-routine Covered Services from In-Plan Providers)	$0	20%
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)	$500/admission (one Copayment for mother & newborn)	20%
Emergency Dental Services and Non-Dental Oral Surgery
Surgical Treatment of Non-Dental Conditions in a doctor’s office* (requires Prior Approval; some services are subject to the Outpatient Surgical Services and Procedures Copayment, see Outpatient Surgical Services and Procedures above)	$20/visit	20%
Emergency dental care in an Emergency Room	$50/visit	$50/visit
Emergency dental care in a doctor’s or dentist’s office	$20/visit	20%
Children’s Preventive Dental
Preventive dental services for children under the age of 12 (For Out-of-Plan Providers, you pay the first $25 per child per calendar year)	$0	$25/child per calendar year
Other Services
Home Health Care* (requires Prior Approval)	$0	20%
Hospice Services* (requires Prior Approval)	$0	20%
Durable Medical Equipment (DME), including ostomy supplies* (limited to $3,000 per calendar year; some items require Prior Approval)	20%	20%
Prosthetic Limbs * (requires Prior Approval)	20%	20%
Ambulance and Chair Van Services (Non-emergency transportation services will be covered only if the Member has Prior Approval from HNE. If Prior Approval is not requested, the Member is responsible for all costs.)	$25/Member per day	$25/Member per day
Kidney Dialysis	$0	20%
Nutritional Support (requires Prior Approval)	$0 (Not covered without Prior Approval)	$0 (Not covered without Prior Approval)
Cardiac Rehabilitation	$20/visit	20%
Wigs (Scalp Hair Prostheses) for hair loss due to treatment of any form of cancer or leukemia.	Covered up to $350 per calendar year for hair loss due to treatment of any form of cancer or leukemia. No authorization required.
Speech, Hearing, and Language Disorders (Outpatient)	$20/visit	20%
Nutritional Counseling (maximum of four visits per calendar year)	$20/visit	20%
Human Organ Transplants and Bone Marrow Transplant* (requires Prior Approval)	$500/admission	20% (If you do not request Prior Approval, Deductible & Coinsurance do not count toward your Maximum Coinsurance plus Deductible amount.)
Mental Health and Substance Abuse Services (requires Prior Approval)
Mental Health Services:
Inpatient services* (care for some conditions may be limited to 60 days per calendar year)	$500/admission	20%
Outpatient services* (care for some conditions may be limited to 24 visits per calendar year) In-Plan: Requires Prior Approval Out-of-Plan: Requires Prior Approval after 10^th visit	$20/visit	20%
Substance Abuse Services
Inpatient services* (maximum 30 days per calendar year)	$500/admission	20%
Outpatient services* (maximum of 20 visits per calendar year) In-Plan: Requires Prior Approval Out-of-Plan: Requires Prior Approval after 10^th visit	Visits 1-8: $10/visit Visits 9-20: $20/visit	20%
HNE covers services for treatment of alcoholism up to a limit of 30 days per Calendar year for inpatient services, and $500 per Calendar Year for outpatient services. The Substance Abuse services member payment responsibilities listed above apply to these services. Requires Prior Approval.

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