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Health New England Medicare Premium (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Health New England Medicare Premium (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Health New England Medicare Premium (HMO) in 2026, please refer to our full plan details page.
Health New England Medicare Premium (HMO) is a HMO plan offered by Baystate Health, Inc. available for enrollment in 2025 to people living in Hampden, Hampshire, Franklin, Berkshire Counties. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Health New England Medicare Premium (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Health New England Medicare Premium (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Health New England Medicare Premium (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $168.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $350.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Health New England Medicare Premium (HMO) plan features an annual drug deductible of $350. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month, 2-month, or 3-month supply at a preferred pharmacy, or a $5 copay for a 1-month supply at a standard pharmacy. Tier 2 generic drugs require a $10 copay for a 1-month supply at preferred pharmacies compared to a $20 copay at standard pharmacies. Tier 3 preferred brand drugs cost a $45 copay for a 1-month supply at preferred pharmacies, while Tier 4 non-preferred drugs require a 40% coinsurance across all pharmacies. For Tier 5 specialty drugs, you will pay a 29% coinsurance for a 1-month supply at both preferred and standard pharmacies. Additionally, you can receive a 3-month supply of Tier 1 drugs with no copay when using preferred mail-order services.
Additional Benefits
The Health New England Medicare Premium (HMO) plan offers comprehensive medical coverage with no copays or coinsurance for primary care, routine preventive services, and home health care. For inpatient hospital stays, members pay a $150 daily copay for the first seven days and no copay thereafter, with no coinsurance required. Outpatient hospital services feature copays ranging from no copay up to $200, while specialist visits require a $30 copay. Additional benefits include routine dental care and eyewear with no copay, subject to annual maximum limits of $1,040 and $300 respectively. Routine hearing exams also feature no copay, though fitting evaluations require a $30 copay and prescription hearing aids carry a copay between $499 and $999. Members can also take advantage of acupuncture, chronic illness meals, and an over-the-counter reimbursement benefit of up to $75 every three months with no copays.
Inpatient Hospital See details
Health New England Medicare Premium (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $150 daily copay for days 1 through 7 and no copay for days 8 through 90. Additional acute days are fully covered with no copay, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Health New England Medicare Premium (HMO) covers outpatient hospital services with a $0 to $200 copay and observation services with a $200 copay, both featuring no coinsurance. Ambulatory surgical center services require a $100 copay, outpatient substance abuse sessions carry a $30 copay, and outpatient blood services are provided with no copay or coinsurance.
Partial Hospitalization See details
Health New England Medicare Premium (HMO) covers partial hospitalization services with a $50.00 copay and no coinsurance. Prior authorization is required for this covered benefit.
Ambulance and Transportation Services See details
Health New England Medicare Premium (HMO) covers ground and air ambulance services with a $350 copay and no coinsurance. Transportation services are partially covered, offering unlimited one-way rides to plan-approved locations with no copay and no coinsurance, while transport to any other health-related locations is not covered.
Emergency Services See details
Health New England Medicare Premium (HMO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $50 copay, both with no coinsurance. Worldwide emergency care, urgent care, and emergency transportation are also covered with no coinsurance and copays of $130, $50, and $350, respectively.
Primary Care See details
Health New England Medicare Premium (HMO) provides primary care, telehealth, and opioid treatment services with no copay and no coinsurance, while specialist visits, physical, occupational, speech, mental health, and psychiatric therapies require a $30 copay and no coinsurance. Other healthcare professional services feature a copay of $0 to $30 with no coinsurance, whereas chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by Health New England Medicare Premium (HMO) with no copay and no coinsurance for annual physicals, kidney disease education, and diabetes self-management training. This benefit is partially covered, as several additional services—including health education, in-home safety assessments, personal emergency response systems, and alternative therapies—are not covered.
Hearing Services See details
Hearing services are partially covered by Health New England Medicare Premium (HMO) with no deductible and no coinsurance, featuring one annual routine exam with no copay and one fitting evaluation with a $30 copay. Prescription hearing aids are covered with a copay of $499 to $999 and no coinsurance for up to two aids per year, but OTC hearing aids and inner ear, outer ear, or over-the-ear prescription models are not covered.
Vision Services See details
Health New England Medicare Premium (HMO) covers vision services, including eye exams with a $30 copay and no coinsurance. Eyewear is also covered with no copay and no coinsurance, up to a $300 combined maximum limit per year.
Dental Services See details
Health New England Medicare Premium (HMO) covers dental services, including Medicare-covered dental with a $30 to $200 copay, no coinsurance, and prior authorization requirements. Other preventive and comprehensive dental services are covered with no copay and no coinsurance up to a maximum annual benefit of $1,040.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Health New England Medicare Premium (HMO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs carry a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Health New England Medicare Premium (HMO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Health New England Medicare Premium (HMO) partially covers medical equipment with no copay and a 20% coinsurance, subject to prior authorization. Under this plan, durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes or inserts are covered, but diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Health New England Medicare Premium (HMO) partially covers diagnostic and radiological services, as diagnostic procedures, tests, and lab services are not covered. Covered radiological services require prior authorization and include diagnostic radiological services with no copay, outpatient X-rays with a $20 copay, and therapeutic radiological services with a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Health New England Medicare Premium (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Health New England Medicare Premium (HMO) plan with no coinsurance and a $20 copay. Pulmonary rehabilitation, intensive cardiac rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD) are also covered with a copayment and no coinsurance.
Skilled Nursing Facility (SNF) See details
Health New England Medicare Premium (HMO) covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 to 20 and days 51 to 100, a $150 copay for days 21 to 50, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Health New England Medicare Premium (HMO) covers acupuncture, over-the-counter (OTC) items, and chronic illness meals with no copay and no coinsurance, though other services like Nicotine Replacement Therapy, Naloxone, and dual-eligible SNP benefits are not covered. The OTC benefit provides up to $75 every three months via reimbursement, while acupuncture treatments and meal benefits have no maximum coverage limits.
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