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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 2025, 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 3.5 out of 5 stars in 2025.
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 has an enhanced alternative drug benefit. The plan has a $350 deductible. After the deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $10 copay at a preferred pharmacy, while preferred brand drugs have 38% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for Part D covered drugs.
Additional Benefits
The Health New England Medicare Premium (HMO) plan offers a variety of benefits with varying costs. Inpatient hospital stays require a copay, while outpatient services range from no copay to $200. Emergency services have a copay, which is waived if admitted to the hospital within 24 hours. This plan covers primary care, specialist visits, mental health, and physical therapy services with a $20-$30 copay. Additionally, the plan includes hearing, vision, and dental coverage. The plan also offers home health services, and covers services like ambulance, diagnostic and radiological services, and skilled nursing facility (SNF) services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $150 copay for days 1-6, and no copay for days 7-90, with additional days covered with no copay. Inpatient Hospital Psychiatric services have the same cost-sharing structure as Inpatient Hospital-Acute. Non-Medicare-covered stays and upgrades are not covered for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered stays are not covered for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered under the Health New England Medicare Premium (HMO) plan, with copays ranging from $0 to $200. Observation Services have a $200 copay, while Ambulatory Surgical Center (ASC) Services have a $100 copay. Outpatient Substance Abuse Services, including individual and group sessions, have a copay of $30. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Health New England Medicare Premium (HMO) plan with a $55 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Health New England Medicare Premium (HMO) plan. Ground and air ambulance services have a $250 copay, but there is no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency services are covered, with a $125 copay, and no coinsurance, and the copay is waived if admitted to the hospital within 24 hours. Urgently needed services have a $55 copay and no coinsurance, while worldwide emergency services include a $125 copay for worldwide emergency coverage, a $55 copay for worldwide urgent coverage, and a $250 copay for worldwide emergency transportation, with no coinsurance.
Primary Care See details
The Health New England Medicare Premium (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy with a $30 copay, specialist services with a $30 copay, and mental health services with a $30 copay for individual and group sessions. The plan also covers physical therapy and speech-language pathology services with a $30 copay, additional telehealth benefits, and opioid treatment program services. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services include coverage for Medicare-covered preventive services with prior authorization, annual physical exams, and additional preventive services, with a maximum plan benefit coverage amount for wigs for hair loss related to chemotherapy. Other services like health education, in-home safety assessments, and counseling services are not covered.
Hearing Services See details
Hearing Services include hearing exams and prescription hearing aids. Hearing exams have a $30 copay, while prescription hearing aids have a copay between $499 and $999, depending on the type.
Vision Services See details
Vision Services include coverage for eye exams with a $30 copay, as well as coverage for eyewear including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, with a combined maximum benefit of $200 every two years. Routine eye exams are covered once per year.
Dental Services See details
The Health New England Medicare Premium (HMO) plan covers dental services, including oral exams, dental x-rays, and other services, with a copay of $30-$200, and a maximum annual benefit of $975. Orthodontic services, restorative services, and other dental services are also covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are covered with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Health New England Medicare Premium (HMO) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts with a 20% coinsurance. Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Health New England Medicare Premium (HMO) plan. Diagnostic services have no copay, but diagnostic procedures/tests and lab services are not covered. Diagnostic Radiological Services have a copay of at most $175.00, and Therapeutic Radiological Services have a coinsurance of at most 20%. Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Health New England Medicare Premium (HMO) plan with no copay and no coinsurance, but require authorization. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Health New England Medicare Premium (HMO) plan. The plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Health New England Medicare Premium (HMO) plan with prior authorization required. There is no copay for days 1-20 and days 51-100, but a $150 copay for days 21-50. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes acupuncture, over-the-counter (OTC) items, and a meal benefit. Acupuncture is covered with no copay, and OTC items are covered up to $65 every three months. The meal benefit is for a chronic illness. Services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and several others are not covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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