Health New England Medicare Premium No Rx (HMO)
H8578 - 003 - 0
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Health New England Medicare Premium No Rx (HMO) is a Medicare Advantage (Part C) Plan by Health New England Medicare Advantage Plans.
This page features plan details for 2024 Health New England Medicare Premium No Rx (HMO) H8578 – 003 – 0 available in Hampden, Hampshire, Franklin, Berkshire Counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Health New England Medicare Premium No Rx (HMO) is offered in the following locations.
Plan Overview
Health New England Medicare Premium No Rx (HMO) offers the following coverage and cost-sharing.
| Insurer: | Health New England Medicare Advantage Plans |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,400.00 |
| Drugs Covered: | No |
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Premium Breakdown
Health New England Medicare Premium No Rx (HMO) has a monthly premium of $79.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $79.00 | $0.00 | $253.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Health New England Medicare Premium No Rx (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $4,400 In-network |
| No |
| In-network | No |
| $0-100 copay per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $20 copay per visit (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $40 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $0-150 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $10 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $20 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $499-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| $200 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $20 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| $150 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is not required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $150 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $20 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $20 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $20 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $20 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $130 per day for days 21 through 50 $0 per day for days 51 through 100 (Authorization is required.) (Referral is not required.) |
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Table of Contents
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