NHP Prime HMO (PD) 500/1000 20/20
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?
$500/Individual $1,000/Family per benefit
period. Doesn’t apply to preventive care, most
outpatient visits (including mental/ behavioral
health/dental and substance use disorder),
prescription drug coverage, emergency care and
urgent 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-ofpocket limit on my
expenses?
Yes $2,000/Individual , 4,000/Family per
benefit period for Medical, Behavioral Health
and Dental combined.
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.
What is not included in
the out-of-pocket limit?
Premiums and health care this plan doesn’t
cover.
Even though you pay these expenses, they do not count toward the outof-pocket limit.
No
The chart starting on page 2 describes any limits on what the plan will pay
for specific covered services, such as office visits.
Is there an overall
annual limit on what
the plan pays?
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.
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 innetwork 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.
Do I need a referral to
see a specialist?
Yes, you need a written or oral referral to see a
specialist.
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.
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.
1 of 8
NHP Prime HMO (PD) 500/1000 20/20
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Are there services this
plan doesn’t cover?
Coverage Period: Beginning on or after 1/1/2015
Coverage for: All Coverage Tiers | Plan Type: HMO
Some of the services this plan doesn’t cover are listed on page 5. See your
policy or plan document for additional information about excluded
services.
Yes

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
Out-ofIn-network Provider
network
Provider
Limitations & Exceptions
Primary care visit to treat
an injury or illness
$20 copay/visit
Not covered
--none--
Specialist visit
$20 copay/visit
Not covered
--none--
Other practitioner office
visit
$20 copay/visit for
chiropractor
Not covered
Chiropractic care covered up to 12 visits per
member per benefit period.
Preventive care/
screening/immunization
No charge
Not covered
Tests for specific conditions during an annual
exam may be subject to cost sharing.
Diagnostic test (x-ray,
blood work)
No charge after deductible
Not covered
--none--
Imaging (CT/PET scans,
MRIs)
No charge after 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.
2 of 8
NHP Prime HMO (PD) 500/1000 20/20
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
If you have a hospital
stay
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
Generic drugs
Retail: $15 copay
Maintenance 90: $30 copay
Not covered
No charge for birth control and smoking cessation
drugs
Preferred brand drugs
Retail: $25 copay
Maintenance 90: $50 copay
Not covered
May require prior authorization
Non-preferred brand
drugs
Retail: $45 copay
Maintenance 90: $135 copay
Not covered
May require prior authorization
Specialty drugs
Generic: $15 copay
Preferred brand-name: $25
copay
Non-preferred brand name: $45
copay
Not covered
Copay based on tier of specialty drug.
Prior authorization required for specialty drugs.
Facility fee (e.g.,
ambulatory surgery
center)
No charge after deductible
Not covered
May require prior authorization
Physician/surgeon fees
No charge after deductible
Not covered
--none--
Emergency room services
$100 copay/visit
$100 copay/visit
Emergency room copay waived if admitted to
hospital for inpatient care
Emergency medical
transportation
No charge after deductible
No charge after
deductible
--none--
Urgent care
$20 copay/visit
$20 copay/visit
--none--
Facility fee (e.g., hospital
room)
No charge after deductible
Not covered
May require prior authorization
Physician/surgeon fee
No charge after deductible
Not covered
--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 (PD) 500/1000 20/20
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
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
Mental/behavioral health
outpatient services
$20 copay/visit
Not covered
Eight initial visits combined for Mental/behavioral
health or Substance use, then authorization
required for additional visits.
Mental/behavioral health
inpatient services
No charge after deductible
Not covered
May require prior authorization
Substance use disorder
outpatient services
$20 copay/visit
Not covered
Eight initial visits combined for Mental/behavioral
health or Substance use, then authorization
required for additional visits.
Substance use disorder
inpatient services
No charge after deductible
Not covered
May require prior authorization
Prenatal and postnatal
care
No charge for routine
prenatal and postnatal care
Not covered
--none--
Delivery and all inpatient
services
No charge after 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.
4 of 8
NHP Prime HMO (PD) 500/1000 20/20
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May
Need
Home health care
No charge
Limitations & Exceptions
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
Outpatient: $20 copay/visit
Inpatient: No charge after
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
No charge after 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
No charge
Not covered
May require prior authorization
Eye exam
$20 copay/visit
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 year per child
covered under this plan up to the age of 19.
If you need help
recovering or have
other special health
needs
If your child needs
dental or eye care
Your cost if you use an
Out-ofIn-network Provider
network
Provider
Not covered
Rehabilitation services
If you need help
recovering or have
other special health
needs
Coverage Period: Beginning on or after 1/1/2015
Coverage for: All Coverage Tiers | Plan Type: HMO
Outpatient: $20 copay/visit
Inpatient: No charge after
deductible
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 (PD) 500/1000 20/20
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 up  Routine foot care (covered for diabetes and
Subscriber or one covered Dependent)
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.
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.
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).
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 (PD) 500/1000 20/20
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)
 Amount owed to providers: $7,540
 Plan pays: $6,890
 Patient pays: $650
 Amount owed to providers: $5,400
 Plan pays: $4,390
 Patient pays: $1,010
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
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
$180
$790
$0
$40
$1,010
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$500
$120
$0
$30
$650
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 (PD) 500/1000 20/20
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?







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-SBC67
NHPHMOMM-SBC79
8 of 8
NHP Prime HMO (PD) 500/1000—20/20
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 plan meets
meets Minimum
Minimum Creditable
Creditable Coverage
Coverage standards that are effective January 1, 2014 as part of the Massachusetts Health 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, 2014. Because these 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 (PD) 500/1000—20/20
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
(Combined): $500 Individual/$1,000 Family
Prescription: None
Out-of-Pocket Maximum per benefit period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical/Dental/Behavioral Health/Prescription
(Combined): $2,000 Individual/$4,000 Family
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
$20 copayment
$20 copayment
No copayment
$20 copayment
$20 copayment
$20 copayment
$20 copayment
Subject to deductible
$20 copayment
$20 copayment
No copayment
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 and Substance Use Care (eight initial visits,
then authorization required for additional visits) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20 copayment
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20 copayment
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 the hospital for inpatient care 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 copayment (waived if admitted to
hospital for inpatient care)
Ambulance Services (emergency transport only). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible
DENTAL CARE
Emergency Dental Care (within 72 hours of accident or injury). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100 copayment (waived if admitted to
hospital for inpatient care)
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: $15 copayment
Preferred brand name: $25 copayment
Non-preferred brand name: $45 copayment
Generic: $30 copayment
Preferred brand name: $50 copayment
Non-preferred brand name: $135 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–$25 copayment
(depending on drug prescribed)
ADDITIONAL SERVICES
Diabetic Supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No copayment
Disposable Medical Supplies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subject to deductible, then 20% coinsurance
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). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Covered up to $2,000 per affected ear every
36 months
Home Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No copayment
Hospice Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No copayment
Oxygen Supplies and Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No copayment
Routine Foot Care (covered for diabetes and some circulatory diseases). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20 copayment
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 or Coinsurance 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 benefit period. For some services, after the
deductible is satisfied, members are also required to
pay a copayment before coverage begins.
All members are responsible for the individual
deductible per benefit period. Family member’s
deductible payments contribute toward the family
deductible per benefit period. The family deductible
can be satisfied by combining the deductibles
paid for by covered family members. Each family
member’s contribution will not exceed the amount
set for an individual deductible.
All medical, dental, behavioral health, and prescription
drug copayments, deductibles, and coinsurance apply
to the annual Out-of-pocket Maximum. Once the
individual out-of-pocket maximum is satisfied, these
services are covered for the member in full through the
remainder of the benefit period.
The family out-of-pocket maximum is satisfied
by combining the deductibles, coinsurance, and
copayment amounts paid by covered family
members. Once the family out-of-pocket maximum
is satisfied, these services are covered for all family
members in full through the remainder of the
benefit period.
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 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 amount. 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; 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.
To make utilization decisions NHP conducts
prospective, concurrent, and retrospective reviews
of the health care services our members use.
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.
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.
Issued November 15, 2014 and effective January 1, 2015
NHPHMOMM: SOB67
NHPHMOMM: SOB69
Neighborhood Health Plan | 253 Summer Street Boston, MA 02210-1120