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Health New England Medicare Plus (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Health New England Medicare Plus (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 Plus (HMO) in 2026, please refer to our full plan details page.
Health New England Medicare Plus (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 Plus (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 Plus (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 Plus (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $113.00. 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 $5000.00 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 Plus (HMO) plan features a $350 prescription drug deductible. For Tier 1 preferred generic drugs, members pay no copay at preferred pharmacies or through preferred mail-order services. Tier 2 generic drugs carry a $10 copay and Tier 3 preferred brand drugs carry a $45 copay for a one-month supply at preferred pharmacies. Standard pharmacies and standard mail order options generally carry higher copays for generic and brand-name drugs. Higher-tier medications require coinsurance, with Tier 4 non-preferred drugs requiring a 36% coinsurance across all pharmacy channels. Tier 5 specialty drugs require a 29% coinsurance for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
The Health New England Medicare Plus (HMO) plan provides comprehensive healthcare coverage with predictable out-of-pocket costs and no deductibles for key services. Beneficiaries enjoy no copay and no coinsurance for preventive care, home health services, and routine dental visits up to an annual maximum of $840. For other medical needs, costs are kept low with a $20 copay for primary care visits, a $40 copay for specialists, and no coinsurance for inpatient hospital stays. The plan also includes valuable extra benefits like a $300 annual eyewear allowance and a $75 quarterly over-the-counter reimbursement with no copay. While most outpatient, emergency, and ambulance services require set copayments, durable medical equipment and dialysis services are covered with a 20% coinsurance.
Inpatient Hospital See details
Health New England Medicare Plus (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $250 copay for days 1 through 7 and no copay for days 8 through 90. Unlimited additional acute days are covered with no copay, though psychiatric additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Health New England Medicare Plus (HMO) covers outpatient services with no coinsurance, including outpatient hospital services with a $0 to $300 copay and observation services with a $300 copay per stay. Ambulatory surgical center services require a $150 copay with no coinsurance, outpatient substance abuse sessions have a $40 copay with no coinsurance, and outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by Health New England Medicare Plus (HMO) with a $50 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Health New England Medicare Plus (HMO) covers ground and air ambulance services with a $350 copay and no coinsurance, though prior authorization is required. Transportation services are partially covered with no copay and no coinsurance for unlimited one-way trips to plan-approved locations, but transportation to any other health-related location is not covered.
Emergency Services See details
Health New England Medicare Plus (HMO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $50, and $350 respectively.
Primary Care See details
Health New England Medicare Plus (HMO) covers primary care visits with a $20 copay and specialist visits with a $40 copay, both with no coinsurance. Physical, occupational, speech, and mental health therapies require a $40 copay and no coinsurance, while opioid treatment has no copay and no coinsurance, and chiropractic and podiatry services are not covered.
Preventive Services See details
Health New England Medicare Plus (HMO) offers preventive services with no copay and no coinsurance, including annual physicals, kidney disease education, and glaucoma screenings. Additional preventive benefits are partially covered; while fitness programs and chemotherapy wigs up to $350 annually are included, services like health education, personal emergency response systems, and in-home safety assessments are not covered.
Hearing Services See details
Health New England Medicare Plus (HMO) covers annual routine hearing exams with no copay and fitting evaluations for a $40 copay, both with no deductible and no coinsurance. Prescription hearing aids are partially covered with a copay of $499 to $999 and no coinsurance, though OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Health New England Medicare Plus (HMO) covers vision services with no deductibles, including eye exams for a $40 copay and no coinsurance. Eyewear is also covered with no copay and no coinsurance, providing a $300 maximum annual benefit for contacts, lenses, frames, and upgrades.
Dental Services See details
Health New England Medicare Plus (HMO) covers Medicare-covered dental services with a $40 to $300 copay and no coinsurance. Preventive and comprehensive dental services, such as cleanings, exams, and restorative care, are covered with no copay and no coinsurance up to an annual maximum benefit of $840.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Health New England Medicare Plus (HMO) with no copay, though prior authorization is required. Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a 0% to 20% coinsurance with no copay.
Dialysis Services See details
Dialysis services are covered under the Health New England Medicare Plus (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Health New England Medicare Plus (HMO) covers medical equipment with no copay and a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes. Diabetic equipment is partially covered under this plan, as diabetic supplies are not covered, and prior authorization is required.
Diagnostic and Radiological Services See details
Health New England Medicare Plus (HMO) diagnostic services are partially covered with no copay or coinsurance, excluding diagnostic procedures, tests, and lab services which are not covered. Covered radiological services require prior authorization and feature no copay for diagnostic radiological services, a $25 copay for outpatient X-rays, and a 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered under the Health New England Medicare Plus (HMO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered for some services under the Health New England Medicare Plus (HMO) plan with no coinsurance, though standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered in practice. Standard cardiac rehabilitation services require a $20 copay.
Skilled Nursing Facility (SNF) See details
Health New England Medicare Plus (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 through 20 and days 51 through 100, a $175 daily copay for days 21 through 50, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Health New England Medicare Plus (HMO) covers acupuncture, over-the-counter (OTC) items, and meal benefits for chronic illnesses with no copay and no coinsurance. The OTC benefit provides up to $75 every three months via reimbursement, though nicotine replacement therapy and naloxone are not covered.
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