Network Blue New England Options

Schedule of Benefits

 

This health plan option is a tiered network plan.
This health plan option includes a tiered provider network called HMO Blue New England Options. As a member enrolled in this tiered network plan, you pay different levels of cost share (copayments, coinsurance, and/or deductibles) depending on the benefits tier of certain network providers you choose to furnish your covered services. A network provider’s benefits tier may change from time to time. See below for a description of times when you will be notified about a change to a network provider’s benefits tier. Also, Blue Cross and Blue Shield may reclassify network providers among the benefits tiers of your tiered provider network. Any overall changes to the benefits tiers of the network providers will happen no more than once each calendar year. Blue Cross and Blue Shield will let your group know before overall changes will become effective for your tiered provider network. For help in finding the benefits tier of a network provider, check in the most current provider directory for your tiered network or visit the online provider search tool at www.bluecrossma.com.

Your cost share level depends on the benefits tier of certain network providers.
Under this tiered network plan, you will pay the lowest cost share amount when you receive your covered service from a network primary care provider or general hospital that is designated as an Enhanced Benefits Tier provider. When you select your primary care provider, you should consider whether that primary care provider admits patients to an Enhanced Benefits Tier hospital as this will have a direct effect on the amount of your cost. Your cost for inpatient covered services is determined by the general hospital’s tier status and not based on your primary care provider’s tier status or the fact that your admitting physician is a network specialist. You may also choose to obtain covered services from a network primary care provider or general hospital that is designated as a Standard Benefits Tier provider or a Basic Benefits Tier provider. However, your cost share amount for covered services that are furnished by a Standard Benefits Tier primary care provider or general hospital will usually be more than the cost that you would pay for the same covered service if it is furnished by an Enhanced Benefits Tier primary care provider or general hospital. And likewise, your cost share for covered services that are furnished by a Basic Benefits Tier primary care provider or general hospital will usually be more than the cost share that you would pay for the same covered service if it is furnished by an Enhanced Benefits Tier provider or a Standard Benefits Tier provider. (If a network primary care provider or general hospital is located outside of Massachusetts, that primary care provider or general hospital is considered an Enhanced Benefits Tier provider for determining your cost share amount.)

You have access to emergency medical services at the lowest cost share level.
When you have an emergency medical condition, you should receive care at the nearest emergency room of a general hospital. You will pay the lowest cost share amount for emergency medical care, regardless of the benefits tier of the general hospital. You will pay the lowest cost share amount for emergency medical care, regardless of the benefits tier of the general hospital. If you are admitted directly from the emergency room for inpatient emergency medical care, you will also pay the lowest cost share amount for your inpatient hospital services, even if the general hospital is not an Enhanced Benefits Tier general hospital.

A network provider’s benefits tier may change from time to time.
Blue Cross and Blue Shield may make changes to a network provider’s benefits tier from time to time. If the benefits tier of your primary care provider is changed to a higher cost share benefits tier, Blue Cross and Blue Shield will send you a notice at least 30 days before the change. The notice will explain how you can find a list of primary care providers and their new benefits tiers. It will also tell you how to select a different primary care provider.

The following chart describes all of your cost share amounts for covered services.
This chart is the Schedule of Benefits that is part of your Benefit Description. It describes the cost share amount that you pay for covered services and the benefit limits (if there are any) that apply for covered services. Do not rely on this chart alone. Be sure to read all parts of your Benefit Description to understand the requirements that you must follow to receive all of your coverage. You should also read the descriptions of covered services and the limitations and exclusions that apply for this coverage. These provisions are fully described in your Subscriber Certificate. To receive your health plan coverage, you must be sure to obtain all of your health care services and supplies from covered providers who participate in the HMO Blue New England Options health care network. The service area where your covered services will be furnished includes all counties in Massachusetts, Connecticut, Maine, New Hampshire, Rhose Island, and Vermont. Also, when it is required, you must receive an approved referral from your designated primary care provider or an approval from Blue Cross Blue Shield HMO Blue as outlined in your Benefit Description (see Part 4). You should make sure that you have received the approved referral or the approval from Blue Cross and Blue Shield before you receive the covered services. Otherwise, you may have to pay all costs.

IMPORTANT NOTE: Blue Cross and Blue Shield and/or your group may change the provisions described in this Schedule of Benefits. If this is the case, the change is described in a rider. Be sure to read each rider (if there are any) that applies to your coverage in this health plan to see if it changes this Schedule of Benefits.

Overall Member Cost Share Provisions Enhanced Benefits Tier Standard Benefits Tier Basic Benefits Tier
Deductible
Your deductible per Plan Year:
$0 $0 $0
Out-of-Pocket Maximum None None None
Overall Benefit Maximum None None None

 

Covered Services Enhanced Benefits Tier
Your Cost Is:
Standard Benefits Tier
Your Cost Is:
Basic Benefits Tier
Your Cost Is:
Admissions for Inpatient Medical and Surgical Care
The copayment does not apply to physician or other professional services
In a General Hospital $250 copayment per admission $500 copayment per admission
$300 copayment per admission for selected hospitals
$1,000 copayment per admission
In a Chronic Disease Hospital $250 copayment per admission $250 copayment per admission $250 copayment per admission
In a Rehabilitation Hospital
(60-day benefit limit per member per calendar year)
No charge up to benefit limit; then, you pay all costs No charge up to benefit limit; then, you pay all costs No charge up to benefit limit; then, you pay all costs
In a Skilled Nursing Facility (100-day benefit limit per member per calendar year) No charge up to benefit limit; then, you pay all costs No charge up to benefit limit; then, you pay all costs No charge up to benefit limit; then, you pay all costs
 
Ambulance Services
(ground or air ambulance transport)
Emergency Ambulance No Charge No Charge No Charge
Other Ambulance No Charge No Charge No Charge
 
Cardiac Rehabilitation
Outpatient Services $45 copayment per visit $45 copayment per visit $45 copayment per visit
 
Chiropractor Services
(for members of any age)
Outpatient lab tests and x-rays No Charge No Charge No Charge
Outpatient medical care services, including spinal manipulation $45 copayment per visit $45 copayment per visit $45 copayment per visit
 
Dialysis Services
Outpatient services and home dialysis No charge No Charge No Charge
 
Durable Medical Equipment
Covered medical equipment rented or purchased for home use 20% coinsurance 20% coinsurance 20% coinsurance
One breast pump per birth (rented or purchased) No charge No charge No charge
No coverage is provided for hospital-grade breast pumps.
 
Early Intervention Services
(for an eligible child through age two) No charge No charge No charge
 
Emergency Medical Outpatient Services
Emergency room services $150 copayment per visit $150 copayment per visit $150 copayment per visit
The emergency room copayment is waived if the visit results in your being held for an overnight observation stay or being admitted for inpatient care within 24 hours.
Primary Care Provider services (also includes nurse practitioner, physician assistant, and nurse midwife services when billed by a primary care provider) $15 copayment per office* visit or home visit $25 copayment per office* visit or home visit $45 copayment per office* visit or home visit
Other nurse practitioner, physician assistant, and nurse midwife services (when not billed by a physician) $15 copayment per office* visit or home visit $15 copayment per office* visit or home visit $15 copayment per office* visit or home visit
Other covered provider services (non-hospital) $45 copayment per office* visit or home visit $45 copayment per office* visit or home visit $45 copayment per office* visit or home visit
Hospital Services (outpatient visit) No charge No charge No charge
 
Home Health Care
Home care program No charge No charge No charge
 
Hospice Services
Inpatient or outpatient hospice services for terminally ill No charge No charge No charge
 
Infertility Services
Inpatient services See Admissions for Inpatient Medical and Surgical Care See Admissions for Inpatient Medical and Surgical Care See Admissions for Inpatient Medical and Surgical Care
Outpatient surgical services See Surgery as an Outpatient See Surgery as an Outpatient See Surgery as an Outpatient
Outpatient lab tests and x-rays See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests
Outpatient medical care services See Medical Care Outpatient Visits See Medical Care Outpatient Visits See Medical Care Outpatient Visits
 
Lab Tests, X-Rays, and Other Tests
Outpatient Lab Tests No charge No charge No charge
Outpatient x-rays No charge No charge No charge
Outpatient CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (copayment does not apply to interpretation costs) General Hospitals: $75 copayment per category of test per service date
Other Providers: $75 copayment per category of test per service date
General Hospitals: $150 copayment per category of test per service date
Other Providers: $75 copayment per category of test per service date
General Hospitals: $250 copayment per category of test per service date
Other Providers: $75 copayment per category of test per service date
For these advanced imaging tests, your copayment will not be more than a total of $375 in a calendar year.
Other outpatient tests and preoperative tests No Charge No Charge No Charge
 
Maternity Services and Well Newborn Inpatient Care (includes $90/$45 for childbirth classes)
Maternity admissions (includes delivery and postnatal care) See Admissions for Inpatient Medical and Surgical Care See Admissions for Inpatient Medical and Surgical Care See Admissions for Inpatient Medical and Surgical Care
Delivery and postnatal Care No Charge No Charge No Charge
Prenatal Care No Charge No Charge No Charge
Well newborn care during enrolled mother’s maternity admission No Charge No Charge No Charge
 
Medical Care Outpatient Visits (includes syringes and needles dispensed during a visit)
Primary care provider services, (also includes nurse practitioner, physician assistant, and nurse midwife services when billed by a primary care physician) $15 copayment per office or home visit $25 copayment per office or home visit $45 copayment per office or home visit
Other nurse practitioner, physician assistant, and nurse midwife services (when not billed by a physician) $15 copayment per office or home visit $15 copayment per office or home visit $15 copayment per office or home visit
Other covered provider services (non-hospital) $45 copayment per office or home visit $45 copayment per office or home visit $45 copayment per office or home visit
Hospital outpatient services No charge No charge No charge
 
Medical Formulas (includes certain medical formulas and low protein foods)
$5,000 benefit limit per member per calendar year for low protein foods No charge for covered services; otherwise you pay all costs No charge for covered services; otherwise you pay all costs No charge for covered services; otherwise you pay all costs
 
Mental Health and Substance Abuse Treatment
Refer to your Benefit Description for more information
Inpatient admissions in a General Hospital See Admissions for Inpatient Medical and Surgical Care See Admissions for Inpatient Medical and Surgical Care See Admissions for Inpatient Medical and Surgical Care
Inpatient admissions in a Mental Hospital or Substance Abuse Facility $250 copayment per admission $250 copayment per admission $250 copayment per admission
Outpatient services $15 copayment per visit; or no charge for hospital services $15 copayment per visit; or no charge for hospital services $15 copayment per visit; or no charge for hospital services
 
Oxygen and Respiratory Therapy
Oxygen and Equipment for its administration No charge No charge No charge
Outpatient respiratory therapy No charge No charge No charge
 
Podiatry Care
Outpatient lab tests and x-rays See Lab Tests, X-Rays and Other Tests See Lab Tests, X-Rays and Other Tests See Lab Tests, X-Rays and Other Tests
Outpatient surgical services See Surgery as an Outpatient See Surgery as an Outpatient See Surgery as an Outpatient
Outpatient medical services See Medical Care Outpatient Visits See Medical Care Outpatient Visits See Medical Care Outpatient Visits
 
Prescription Drugs and Supplies
Drug formulary (includes syringes and needles)
For insulin infusion pumps, you pay nothing
Retail Pharmacy (up to 30-day supply) Tier 1: $15 copayment
Tier 2: $30 copayment
Tier 3: $50 copayment
Tier 1: $15 copayment
Tier 2: $30 copayment
Tier 3: $50 copayment
Tier 1: $15 copayment
Tier 2: $30 copayment
Tier 3: $50 copayment
Full coverage is provider for Tier 1 birth control drugs and devices. For these covered services, you pay nothing.
Mail Service Pharmacy (up to 90 day supply) Tier 1: $30 copayment
Tier 2: $60 copayment
Tier 3: $150 copayment
Tier 1: $30 copayment
Tier 2: $60 copayment
Tier 3: $150 copayment
Tier 1: $30 copayment
Tier 2: $60 copayment
Tier 3: $150 copayment
Full coverage is provided for Tier 1 birth control drugs and devices. For these covered services, you pay nothing.
 
Preventive Health Care Services
Includes: $150 Fitness Benefit
$150 Weight Loss Program Benefit
Refer to your Benefit Description for a complete description of covered services
Routine pediatric care No charge No charge No charge
These covered services include (but are not limited to): routine exams; immunizations; routine lab tests and x-rays; and blood tests to screen for lead poisoning.
Preventive dental care No charge for a member under age 18 for treatment of cleft lip and cleft palate; otherwise, you pay all costs. No charge for a member under age 18 for treatment of cleft lip and cleft palate; otherwise, you pay all costs. No charge for a member under age 18 for treatment of cleft lip and cleft palate; otherwise, you pay all costs.
Routine adult exams and tests No charge No charge No charge
These covered services include (but are not limited to): routine exams; immunizations; routine lab tests and x-rays; routine mammograms at least once between age 35 through 39 and once per calendar year for age 40 or older; blood tests to screen for lead poisoning; and routine colonoscopies.
Routine GYN exams (once per member per calendar year) No charge for covered services; otherwise, you pay all costs No charge for covered services; otherwise, you pay all costs No charge for covered services; otherwise, you pay all costs
These covered services include a routine Pap smear test once per member per calendar year.
Family planning No charge No charge No charge
Routine hearing care services Routine Hearing Exams/Tests: No charge
Hearing Aids: Not covered; you pay all costs
Routine Hearing Exams/Tests: No charge
Hearing Aids: Not covered; you pay all costs
Routine Hearing Exams/Tests: No charge
Hearing Aids: Not covered; you pay all costs
These covered services include newborn hearing screening tests
Routine vision exams (one exam per member every 24 months) No charge for covered exams; otherwise, you pay all costs No charge for covered exams; otherwise, you pay all costs No charge for covered exams; otherwise, you pay all costs
 
Prosthetic Devices
Ostomy supplies No charge No charge No charge
Artificial limb devices (includes repairs) and other external prosthetics devices 20% coinsurance 20% coinsurance 20% coinsurance
 
Radiation Therapy and Chemotherapy
Outpatient services No charge No charge No charge
 
Second Opinions
Outpatient second and third surgical opinions See Medical Care Outpatient Visits See Medical Care Outpatient Visits See Medical Care Outpatient Visits
Short-term Rehabilitation Therapy
Outpatient physical, occupational, and speech therapy (60-visit benefit limit per member per calendar year) $45 copayment per visit for covered services; otherwise you pay all costs $45 copayment per visit for covered services; otherwise you pay all costs $45 copayment per visit for covered services; otherwise you pay all costs
This benefit limit does not apply for: speech therapy; and when any of these covered services are furnished to treat autism spectrum disorders or as part of covered home health care.
Speech, Hearing and Language Disorder Treatment
Outpatient diagnostic tests See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests
Outpatient speech therapy See Short-Term Rehabilitation Therapy See Short-Term Rehabilitation Therapy See Short-Term Rehabilitation Therapy
Outpatient medical care services See Medical Care Outpatient Visits See Medical Care Outpatient Visits See Medical Care Outpatient Visits
 
Surgery as an Outpatient
(includes removal of impacted teeth that are fully or partially imbedded in the bone)
Surgical day care unit of hospital for day surgery services $150 copayment per admission $250 copayment per admission $500 copayment per admission
Ambulatory surgical facility for day surgery services $150 copayment per admission $150 copayment per admission $150 copayment per admission
Sterilization procedure for a female member when performed as the primary procedure for family planning reasons No charge No charge No charge
Primary care provider services (also includes nurse practitioner, physician assistant, and nurse midwife services when billed by a primary care physician) $15 copayment per office visit $25 copayment per office visit $45 copayment per office visit
Other nurse practitioner, physician assistant, and nurse midwife services (when not billed by a primary care physician) $15 copayment per office visit $15 copayment per office visit $15 copayment per office visit
Other covered provider services (non-hospital) $45 copayment per office visit $45 copayment per office visit $45 copayment per office visit
 
TMJ Disorder Treatment
Outpatient diagostic x-rays See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests
Outpatient surgical services See Surgery as an Outpatient See Surgery as an Outpatient See Surgery as an Outpatient
Outpatient physical therapy (short-term rehabilitation therapy benfit limit applies) See Short-Term Rehabilitation Therapy See Short-Term Rehabilitation Therapy See Short-Term Rehabilitation Therapy
Outpatient medical care services See Medical Care Outpatient Visits See Medical Care Outpatient Visits See Medical Care Outpatient Visits