NHP Prime HMO HSA (PD) 2000/4000

NHP Prime HMO HSA (PD) 2000/4000
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning on or after 1/1/2015
Coverage for: All Coverage Tiers | Plan Type: HMO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.nhp.org or by calling Customer Service at 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY).
Important Questions
Answers
Why this Matters:
What is the overall
deductible?
$2,000/Individual Policy,$4,000/Family
Policy per benefit period.With family
coverage, the individual deductible does not
apply. The entire family deductible must be
met before benefits are payable for anyone in
the family. Deductible doesn’t apply to
preventive care.
You must pay all the costs up to the deductible amount before this plan begins to pay for
covered services you use. Check your policy or plan document to see when the deductible
starts over (usually, but not always, January 1). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific
services?
No
You don’t have to meet deductibles for specific services, but see the chart starting on
page 2 for other costs for services this plan covers.
Is there an out-of-pocket
limit on my expenses?
What is not included in
the out-of-pocket limit?
Is there an overall annual
limit on what the plan pays?
Yes $5000/Individual Policy $10,000/Family
Policy per benefit period. With family
coverage, the individual out-of-pocket limit
does not apply. The out-of-pocket limit may
be met by any combination of covered family
members. Once the out-of-pocket limit has
been reached, no additional member cost
sharing will be applied for the remainder of
the benefit period.
Premiums and health care this plan doesn’t
cover
No
Does this plan use a
network of providers?
Yes For a list of in-network providers, see
www.nhp.org or call 1-866-414-5533.
Do I need a referral to see
a specialist?
Are there services this
plan doesn’t cover?
Yes, you need a written or oral referral to
see a specialist.
Yes
The out-of-pocket limit is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for your
health care expenses.
Even though you pay these expenses, they do not count toward the out-of-pocket limit.
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
If you use an in-network doctor or other health care provider, this plan will pay some or
all of the costs of covered services. Be aware, your in-network doctor or hospital may use
an out-of-network provider for some services. Plans use the term in-network, preferred,
or participating for providers in their network. See the chart starting on page 2 for how
this plan pays different kinds of providers.
This plan will pay some or all of the costs to see a specialist for covered services but only
if you have the plan’s permission before you see the specialist.
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan
document for additional information about excluded services.
Questions: Call 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) or visit us at www.nhp.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.nhp.org or call Customer Service at 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) to request a copy.
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NHP Prime HMO HSA (PD) 2000/4000
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning on or after 1/1/2015
Coverage for: All Coverage Tiers | Plan Type: HMO

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
 Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if
you haven’t met your deductible.
 The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
 This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a health
care provider’s office
or clinic
If you have a test
Services You May
Need
Your cost if you use an
In-network Provider
Out-of-network
Provider
Limitations & Exceptions
Primary care visit to treat an
injury or illness
Subject to deductible
Not covered
---none---
Specialist visit
Subject to deductible
Not covered
---none---
Other practitioner office
visit
Subject to deductible
Not covered
Chiropractic care covered up to 12
visits per member per benefit period.
Preventive care/screening/
immunization
No copayment
Not covered
Tests for specific conditions during an
annual exam may be subject to cost
sharing.
Diagnostic test (x-ray, blood
work)
Subject to deductible
Not covered
---none---
Imaging (CT/PET scans,
MRIs)
Subject to deductible
Not covered
May require prior authorization
Questions: Call 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) or visit us at www.nhp.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.nhp.org or call Customer Service at 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) to request a copy.
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NHP Prime HMO HSA (PD) 2000/4000
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage is available
at www.nhp.org.
If you have
outpatient surgery
If you need
immediate medical
attention
Services You May
Need
Coverage Period: Beginning on or after 1/1/2015
Coverage for: All Coverage Tiers | Plan Type: HMO
Your cost if you use an
In-network Provider
Out-of-network
Provider
Limitations & Exceptions
Generic drugs
Retail: $50 copay after deductible
Maintenance 90: $100 copay after
deductible
Not covered
No charge for birth control and
smoking cessation drugs
Preferred brand drugs
Retail: $80 copay after deductible
Maintenance 90: $160 copay after
deductible
Not covered
May require prior authorization
Non-preferred brand drugs
Retail: $120 copay after deductible
Maintenance 90: $360 copay after
deductible
Not covered
May require prior authorization
Specialty drugs
Generic: $50 copay after deductible
Preferred brand-name: $80 copay
after deductible
Non-preferred brand name: $120 copay
after deductible
Not covered
Copay based on tier of specialty drug.
Prior authorization required for
specialty drugs.
Facility fee (e.g., ambulatory
surgery center)
Subject to deductible
Not covered
May require prior authorization
Physician/surgeon fees
Subject to deductible
Not covered
---none---
Emergency room services
Subject to deductible
Subject to
deductible
Emergency room copay waived if
admitted to hospital for inpatient care.
Emergency medical
transportation
Subject to deductible
Subject to
deductible
---none---
Urgent care
Subject to deductible
Subject to
deductible
---none---
Questions: Call 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) or visit us at www.nhp.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.nhp.org or call Customer Service at 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) to request a copy.
3 of 8
NHP Prime HMO HSA (PD) 2000/4000
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
If you have a
hospital stay
If you have mental
health, behavioral
health, or substance
use needs
Services You May Need
Coverage Period: Beginning on or after 1/1/2015
Coverage for: All Coverage Tiers | Plan Type: HMO
Your cost if you use an
Out-ofIn-network Provider
network
Provider
Limitations & Exceptions
Facility fee (e.g., hospital room)
Subject to deductible
Not covered
May require prior authorization
Physician/surgeon fee
Subject to deductible
Not covered
---none---
Mental/behavioral health
outpatient services
Subject to deductible
Not covered
Eight initial visits combined for
Mental/behavioral health or Substance use,
then authorization required for additional
visits
Mental/behavioral health
inpatient services
Subject to deductible
Not covered
May require prior authorization
Substance use disorder
outpatient services
Subject to deductible
Not covered
Eight initial visits combined for
Mental/behavioral health or Substance use,
then authorization required for additional
visits
Substance use disorder
inpatient services
Subject to deductible
Not covered
May require prior authorization
Prenatal and postnatal care
No charge for routine
prenatal and postnatal care
after deductible
Not covered
---none---
Delivery and all inpatient
services
Subject to deductible
Not covered
May require prior authorization
If you are pregnant
Questions: Call 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) or visit us at www.nhp.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.nhp.org or call Customer Service at 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) to request a copy.
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NHP Prime HMO HSA (PD) 2000/4000
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Home health care
Rehabilitation services
If you need help
recovering or have
other special health
needs
If you need help
recovering or have
other special health
needs
If your child needs
dental or eye care
Coverage Period: Beginning on or after 1/1/2015
Coverage for: All Coverage Tiers | Plan Type: HMO
Your cost if you use an
Out-ofIn-network Provider
network
Provider
Subject to deductible
Subject to deductible
Limitations & Exceptions
Not covered
May require prior authorization
Not covered
Outpatient: Covered up to 60 combined
visits per benefit period for Physical
Therapy/Occupational Therapy. Inpatient:
Covered up to 60 days per benefit period.
Prior authorization required.
Habilitation services
Subject to deductible
Not covered
Outpatient: Covered up to 60 combined
visits per benefit period for Physical
Therapy/Occupational Therapy. Inpatient:
Covered up to 60 days per benefit period.
Prior authorization required. Cost and
coverage limits are waived for early
intervention services for eligible children.
Skilled nursing care
Subject to deductible
Not covered
Covered up to 100 days per benefit period.
May require prior authorization.
Durable medical equipment
20% coinsurance after
deductible
Not covered
May require prior authorization. No charge
for electric breast pump (one every three
years).
Hospice service
Subject to deductible
Not covered
May require prior authorization
Eye exam
No copayment
Not covered
One eye exam every 12 months per child
covered under this plan
Glasses
Not covered
Not covered
---none---
Dental check-up
50% coinsurance after
deductible
Not covered
Limited to 2 exams every calendar period per
child covered under this plan up to the age of
19.
Questions: Call 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) or visit us at www.nhp.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.nhp.org or call Customer Service at 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) to request a copy.
5 of 8
NHP Prime HMO HSA (PD) 2000/4000
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning on or after 1/1/2015
Coverage for: All Coverage Tiers | Plan Type: HMO
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
 Acupuncture
 Extraction of infected or impacted wisdom
 Non-emergency care when traveling outside
teeth
(except
when
in
a
hospital
setting)
the U.S.
 Cosmetic surgery
 Long-term care
 Private-duty nursing
 Dental care–adult (you may have coverage
under a separate dental plan)
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
 Bariatric surgery
 Infertility treatment
 Weight loss program (coverage for six months
of membership fees in a Jenny Craig or Weight
 Chiropractic care
 Routine eye exam (adult)
Watchers program for either a covered
 Hearing aids (age 21 and younger, covered
 Routine foot care (covered for diabetes and
Subscriber or one covered Dependent)
up to $2,000 per ear every 36 months)
some circulatory diseases)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-866-414-5533. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact Customer Service at 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY).
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value).
This health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services: Para obtener asistencia en Español, llame al 1-866-414-5533.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) or visit us at www.nhp.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.nhp.org or call Customer Service at 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) to request a copy.
6 of 8
NHP Prime HMO HSA (PD) 2000/4000
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Coverage Period: Beginning on or after 1/1/2015
Coverage for: All Coverage Tiers | Plan Type: HMO
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
This coverage example assumes an Individual
Policy
This coverage example assumes an Individual
Policy
 Amount owed to
providers: $7,540
 Plan pays: $5,160
 Patient pays: $2,380
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2,000
$350
$0
$30
$2,380
 Amount owed to providers: $5,400
 Plan pays: $2,850
 Patient pays: $2,550
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$430
$2,080
$0
$40
$2,550
Questions: Call 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) or visit us at www.nhp.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.nhp.org or call Customer Service at 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) to request a copy.
7 of 8
NHP Prime HMO HSA (PD) 2000/4000
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning on or after 1/1/2015
Coverage for: All Coverage Tiers | Plan Type: HMO
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?








The patient is on an individual policy.
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
Can I use Coverage Examples
to compare plans?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Yes. When you look at the Summary of
Does the Coverage Example
predict my own care needs?
 No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Questions: Call 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) or visit us at www.nhp.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.nhp.org or call Customer Service at 1-866-414-5533 (toll free) or 1-800-655-1761 (TTY) to request a copy.
NHPHMOMM-SBC63
NHPHMOMM-SBC63F
NHPHMOMM-SBC91
NHPHMOMM-SBC91F
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NHP Prime HMO HSA (PD) 2000/4000
Schedule
of benefits
A Prime HMO plan

This health plan meets
meets Minimum
Minimum Creditable
Creditable Coverage
Coverage standards and will satisfy
the individual mandate that you have health insurance.
MASSACHUSETTS REQUIREMENT TO PURCHASE HEALTH INSURANCE:
As of January 1, 2009, the Massachusetts Health Care Reform Law requires
that Massachusetts residents, eighteen (18) years of age and older, must have
health coverage that meets the Minimum Creditable Coverage standards set
by the Commonwealth Health Insurance Connector, unless waived from the
health insurance requirement based on affordability or individual hardship.
For more information call the Connector at 1-877-MA-ENROLL or visit the
Connector website (www.mahealthconnector.org).
This health
health plan
plan meets
meetsMinimum
MinimumCreditable
Creditable
Coverage
Coverage
standards
standards
thatthat
are are
efeffective
fective January
January1,1,2009
2014as
aspart
partof
ofthe
the Massachusetts
Massachusetts Health
Health Care
Care Reform Law.
If you purchase this plan, you will satisfy the statutory requirement that you have
health insurance meeting these standards.
This disclosure is for minimum creditable coverage standards that are effective
January 1, 2009.
2014. Because
Because these
these standards
standards may change, review your health plan
material each year to determine whether your plan meets the latest standards.
If you have questions about this notice, you may contact the Division of
Insurance by calling 617-521-7794 or visiting its website at www.mass.gov/doi.
nhp.org
NHP Prime HMO HSA (PD) 2000/4000
This Schedule of Benefits is a general description of your coverage as
a member of Neighborhood Health Plan (NHP). For more information
about your benefits, visit www.nhp.org or call NHP Customer Service
at 866-414-5533 (TTY 800-655-1761). To find a provider, please visit
www.nhp.org.
All covered services must be medically necessary and some may
require prior authorization. Please check with your PCP or treating
provider to determine if a prior authorization is necessary. The
NHP Member Handbook may include additional coverage and/or
exclusions not listed on the Schedule of Benefits.
Medical Care Deductible And Out-of-Pocket Maximum
Deductible per benefit period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical/Dental/Behavioral Health
Prescription (Combined): $2,000
Individual Policy/$4,000 Family Policy
With family coverage, the individual deductible does not apply. The entire family deductible
must be met before benefits are payable for anyone in the family. Deductible doesn’t apply to
preventive services.
Out-of-Pocket Maximum per benefit period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical/Dental/Behavioral Health
Prescription (Combined): $5,000
Individual Policy/$10,000 Family Policy
With family coverage, the individual out-of-pocket maximum does not apply. The out-of-pocket maximum
may be met by any combination of covered family members. Once the out-of-pocket maximum has been
reached, no additional member cost sharing will be applied for the remainder of the benefit period.
Outpatient Medical Care
Preventive Services
Annual Physical Exams* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Annual Gynecological Exams* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Immunizations and Vaccinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preventive Laboratory Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Screening Colonoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Screening Mammography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Well Child Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other Primary & Specialty Care Office Visits
Office Visits for Other Primary Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Office Visits for Other Specialty Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Allergy Shots. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cardiac Rehabilitation Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chiropractic Care (12 visits per member per benefit period) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Routine Eye Exams (one visit per member every 12 months) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hearing Exams. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Infertility Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Physical Therapy/Occupational Therapy (up to 60 visits combined per benefit period). . . . . . . . . . . . . . . . . . . . . . .
Speech Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Routine Prenatal and Postnatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No copayment
No copayment
No copayment
No copayment
No copayment
No copayment
No copayment
No copayment
Subject to deductible
Subject to deductible
Subject to deductible
Subject to deductible
Subject to deductible
No copayment
Subject to deductible
Subject to deductible
Subject to deductible
Subject to deductible
Subject to deductible
Other Outpatient Services
Diagnostic, Laboratory, and X-ray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
High-tech Radiology (MRI, CT, PET Scan, Nuclear Cardiac Imaging) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Outpatient Surgery—Facility Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Outpatient Surgery—Professional Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Inpatient Medical Care
Inpatient Medical Services—Facility Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Inpatient Medical Services—Professional Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Inpatient Care in a Skilled Nursing Facility (for up to 100 days per benefit period) . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Inpatient Care in a Skilled Nursing Facility—Professional Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Inpatient Care in a Rehabilitation Facility (for up to 60 days per benefit period) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Inpatient Care in a Rehabilitation Facility—Professional Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Inpatient Maternity—Facility Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Routine Nursery and Newborn Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No copayment
Behavioral Health Services—Outpatient
Mental Health or Substance Use Care (eight initial visits
combined, then authorization required for additional visits). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Behavioral Health Services—Inpatient
Inpatient Mental Health Care—Facility Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inpatient Mental Health Care—Professional Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inpatient Substance Use Detoxification or Rehabilitation—Facility Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inpatient Substance Use Detoxification or Rehabilitation—Professional Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
*Tests for specific conditions during an annual exam may be subject to
cost sharing.
Subject to deductible
Subject to deductible
Subject to deductible
Subject to deductible
The Deductible, Coinsurance, and Copayments for Medical, Dental, Behavioral
Health Services, and Prescription Drug expenses apply to the annual Out-ofPocket Maximum.
Urgent Care
Care for an illness, injury or condition serious enough that a person would seek
immediate care, but not so severe as to require Emergency room care.
Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Emergency Care
If you require emergency medical care, go to the nearest emergency room
or call 911 or your local emergency number. When admitted to a hospital for
emergency care, you or a family member should notify your PCP within 48 hours.
Care you receive in an emergency room, in or out of NHP Service Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Ambulance Services (emergency transport only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Dental Care
Emergency Dental Care (within 72 hours of accident or injury). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible,
then $0 copayment
Pediatric Dental—for children under the age of 19**
Preventive and Diagnostic (oral exams, X-rays, cleanings). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Basic Restorative (fillings, root canal treatment) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Restorative (dentures, crowns). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Orthodontic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Subject to deductible, then 50% coinsurance
Subject to deductible, then 50% coinsurance
Subject to deductible, then 50% coinsurance
Subject to deductible, then 50% coinsurance
Prescription Drugs
With a valid prescription and purchased at a participating pharmacy for up to a 30-day supply . . . . . . . . . . . . . .
Access90: With a valid prescription for a 90-day supply of a maintenance
medication and purchased through the mail or at a participating pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Generic: Subject to deductible,
then $50 copayment
Preferred brand name: Subject to
deductible, then $80 copayment
Non-preferred brand name: Subject to
deductible, then $120 copayment
Generic: Subject to deductible,
then $100 copayment
Preferred brand name: Subject to
deductible, then $160 copayment
Non-preferred brand name: Subject to
deductible, then $360 copayment
Over-the-counter Drugs
For a complete list of over-the-counter drugs, visit www.nhp.org
or call NHP Customer Service at 866-414-5533 (TTY 800-655-1761).
Select generic over-the-counter cough, cold and allergy medicines with a valid
prescription and purchased at a participating pharmacy for up to a 30-day supply . . . . . . . . . . . . . . . . . . . . . . . . . . $0–Subject to deductible,
then $80 (depending on drug prescribed)
Additional Services
Diabetic Supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Disposable Medical Supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Durable Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible, then 20% coinsurance
Early Intervention (from birth up to age three) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No copayment
Fitness Program Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coverage for one month of membership fees
(minimum of $150) at a qualified health club for
either a covered Subscriber or one covered
Dependent (see www.nhp.org for qualifications)
Hearing Aids (age 21 and under). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible. Covered up to $2,000
for each affected ear every 36 months
Home Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Hospice Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Oxygen Supplies and Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Routine Foot Care (covered for diabetes and some circulatory diseases). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
Weight Loss Program Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coverage for six months of membership fees in a
Jenny Craig or Weight Watchers program for
either a covered Subscriber or one covered
Dependent (see www.nhp.org for qualifications)
Wigs (when medically necessary for hair loss due to cancer treatment or other conditions). . . . . . . . . . . . . . . . . . Subject to deductible, then 20% coinsurance
**This policy does include coverage of pediatric dental services as required
under the Federal Patient Protection and Affordable Care Act
This Schedule of Benefits and the NHP Member Handbook (or Subscriber
Agreement) comprise the Evidence of Coverage for NHP members covered on
this health plan.
For questions or concerns about your NHP coverage, call NHP Customer
Service at 866-414-5533 (TTY 800-655-1761), available Monday through Friday,
8:00 a.m.–6:00 p.m. (Thursday 8:00 a.m.–8:00 p.m.)
About Your
NHP Membership
Benefit Period
If you have non-group coverage with NHP, your
benefit period resets on January 1. If you are
enrolled through employer sponsored group coverage with NHP, your benefit period resets on your
employer’s anniversary date.
Copayments, Coinsurance, or Deductibles
Required for Certain Services
Before coverage begins for certain services, you
pay a deductible each benefit period. Your plan
deductible is an amount you pay for certain services each year before NHP starts to pay for those
certain covered services.
Your Health Savings Account (HSA) Compatible
plan uses an Aggregate Deductible and Out-ofPocket Maximum.
If you have individual coverage, you only need to
satisfy the individual deductible and out-of-pocket
maximum amounts. Family amounts do not apply
to you.
If you have family coverage, the individual deductible and out-of-pocket maximum amounts do not
apply. Your entire family deductible must be met
before benefits are payable for anyone in the family (unless otherwise noted). With family coverage,
your entire family out-of-pocket maximum must be
met before the plan starts to pay 100% for covered
services.
As a reminder, under HSA-compatible plans, all
covered services except covered preventive services apply toward satisfaction of the deductible.
Your Primary Care Provider (PCP)
Your PCP arranges your health care and is the first
person you call when you need medical care. Be
sure to check with your PCP to find out office hours
and whether urgent care is offered.
NHP requires the designation of a PCP. You have
the right to designate any PCP who participates in
our network and who is available to accept you or
your family members. For children, you may designate a pediatrician as the PCP. Until you make this
designation, NHP designates one for you.
For information on how to select a PCP, or a list of
the most up-to date provider information, or a list of
participating health care professionals who specialize in obstetrics or gynecology, visit our website at
www.nhp.org, or call NHP Customer Service.
Preventive Care Services
NHP covers eligible preventive services for adults,
women (including pregnant women) and children,
which includes coverage for annual physical
exams, immunizations, well child visits and annual
gynecological exams. For a complete list of eligible
preventive care services, please visit www.nhp.org
or call NHP Customer Service.
For questions or concerns about your NHP coverage, call
NHP Customer Service at 866-414-5533 (TTY 800-655-1761),
Mon.–Fri. 8:00 a.m.–6:00 p.m. (Thurs. 8:00 a.m.–8:00 p.m.).
Primary Care Provider (PCP) and
Obstetrical Rights
You do not need prior authorization from NHP or
from any other person (including a PCP) in order to
obtain access to obstetrical or gynecological care
from a health care professional in our network who
specializes in obstetrics or gynecology. However,
the health care professional may be required to
comply with certain procedures, including obtaining
prior authorization for certain services, following
a pre-approved treatment plan, or procedures for
making referrals.
Urgent Care
If you need urgent care, call your PCP to arrange
where you will receive treatment. Examples of
conditions requiring urgent care include, but are
not limited to, fever, sore throat or an earache.
Emergency Care
In an emergency, go to the nearest emergency facility, or call 911, or your local emergency number.
Please refer to this Schedule of Benefits for your
cost sharing amounts. If you pay a copayment,
it is waived if you are admitted to the hospital for
inpatient care.
All follow-up care must be arranged by your PCP.
You, or someone on your behalf, should notify your
PCP within 48 hours.
Referrals
NHP requires referral for specialist services
provided by in-network NHP Providers, except
the following: Gynecologist or Obstetrician for
routine, preventive or urgent care; Family Planning
services; Outpatient and Diversionary Behavioral
Health Services; Routine Eye Exams; Physical
Therapy; Occupational Therapy; Speech Therapy;
Routine Eye Exam; and Emergency Services.
Utilization Management Program
The Utilization Management standards NHP uses
were created to assure that our members consistently receive high quality, appropriate medical
care. To determine coverage, specific criteria are
used to make Utilization Management decisions.
These criteria are developed by physicians and
meet the standards of national accreditation
organizations. As new treatments and technologies become available, we update our Utilization
Management standards annually.
Prospective Review (Prior Authorization)
Determines in advance if a procedure or treatment
either you or your doctor is requesting is both
medically appropriate and medically necessary.
Concurrent Review
During the course of treatment, such as hospitalization, concurrent review monitors the progress
of treatment and determines for how long it will be
deemed medically necessary.
Retrospective Review
After care has been provided, NHP reviews
treatment outcomes to ensure that the health
care services provided to you met certain quality
standards.
Care Management
When members have a severe or chronic illness
or condition, they may qualify for Care Management. NHP’s care managers work one-on-one
with members and their providers to find the most
appropriate and cost-effective ways to manage
a condition. Together, a treatment plan that best
meets the member’s needs is developed with the
goal of promoting patient education, self-care, and
providing access to the right kinds of health care
services and options.
To learn more about Utilization Management or
Care Management at NHP, please refer to your
NHP Member Handbook or call NHP Customer
Service.
Exclusions
Services or supplies that NHP does not cover
include: Acupuncture; Benefits from other sources;
Diet foods; Educational testing and evaluations;
Massage therapy; Out-of-network providers; Nonemergency care when traveling outside the U.S.
Additional benefit exclusions apply, for a complete
list please refer to your plan’s Benefit Handbook.
To make utilization decisions NHP conducts prospective, concurrent, and retrospective reviews of
the health care services our members use.
Issued November 15, 2014 and effective January 1, 2015
NHPHMOMM: SOB63 NHPHMOMM: SOB63F
NHPHMOMM: SOB91 NHPHMOMM: SOB91F
Neighborhood Health Plan | 253 Summer Street Boston, MA 02210-1120

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