Plan Overview

Limited Network Plan logo

NHP Prime, formerly known as NHP Care, is administered by Neighborhood Health Plan.  The plan is an HMO that provides coverage through the plan’s network of doctors, hospitals, and other providers.  Members must select a Primary Care Provider (PCP) to manage their care and obtain referrals to specialists. 

Contact the plan to see if your doctors and hospitals are in the network.  There are no out-of-network benefits, with the exception of emergency care. 

Specialist Tiering

Neighborhood Health Plan tiers the following specialists based on quality and/or cost efficiency: Cardiologists, Endocrinologists, Gastroenterologists, Obstetrician/Gynecologists, Otolaryngologists (ENTs), Orthopedists, Pulmonologists, and Rheumatologists. Members pay lower office visit copays when they see Tier 1 and Tier 2 specialists.  Contact the plan to see how your provider is rated.

! Your Responsibility

Do your doctors and hospitals participate in NHP Prime?

Contact the Plan.

Plan Contact Information

Contact the plan for additional information on
participating providers and benefits.

NHP Prime1.866.567.9175

 

Calendar Year Deductible - will transition to fiscal year

$300 per individual up to a maximum of $900 per family.

In-Network Out-Of-Pocket Maximum

$5,000 per individual; $10,000 per family

Copays Effective July 1, 2015

Primary Care Provider Office Visit

$20 per visit

Preventive Services

Most covered at 100% - no copay

Specialist Physician Office Visit

Neighborhood Health Plan tiers the following specialists based on quality and/or cost efficiency: Cardiologists, Endocrinologists, Gastroenterologists, Obstetricians/Gynecologists, Otolaryngologists (ENTs), Orthopedists, Pulmonologists, and Rheumatologists. Contact the plan to see how your provider is rated.

***Tier 1 (excellent):  $30 per visit
**Tier 2 (good):          $60 per visit
*Tier 3 (standard): $90 per visit

Retail Clinic

$20 per visit

Outpatient Mental Health and Substance Abuse Care

$20 per visit

Inpatient Hospital Care - Medical (Maximum one copay per person per calendar year quarter; waived if readmitted within 30 days in the same calendar year):
$275 per admission

Outpatient Surgery (Maximum four copays per person per calendar year)

$250 per occurrence

High-Tech Imaging(e.g., MRI, PET and CT scans) (Maximum one copay per day)

$100 per scan

Emergency Room
$100 per visit (waived if admitted)

Prescription Drug

Retail up to 30 day supply:        Mail Order up to 90 day supply:
Tier 1:   $10                                         Tier 1:   $25
Tier 2:   $30                                         Tier 2:   $75
Tier 3:   $65                                       Tier 3:   $165

Who is Eligible?

Employees, Retirees, GIC Retired Municipal Teachers (RMTs), Elderly Governmental Retirees (EGRs), Survivors, and their eligible dependents without Medicare are eligible. 

Where You Live Determines Which Plan You May Enroll In

NHP Prime is available in the following Massachusetts counties:

Barnstable, Bristol, Dukes, Essex, Hampden, Middlesex, Nantucket, Norfolk, Plymouth, Suffolk, Worcester

Handbook

NHP Prime Handbook FY15  doc format of NHP Prime Handbook FY15
file size 1MB

NHP Schedule of Benefits FY15  doc format of NHP Schedule of Benefits FY15

NHP Schedule of Benefits FY15  pdf format of NHP Schedule of Benefits FY15


This information provided by the Group Insurance Commission .