What’s Covered under Boston Medical Center Preferred

Inner Circle

Your primary care physician (PCP) must be chosen from the inner circle. When you receive care from a Boston Medical Center Preferred Inner Circle provider, you are covered in full, in and out of the hospital. You pay only $5 for office visits and routine physical exams and $40 for emergency room care (this fee is waived if you are immediately hospitalized).

Expanded Circle

Boston Medical Center Preferred also gives your primary care physician the ability to refer you to physicians, specialists, and health care facilities in the Expanded Circle; your benefits coverage, however, will be lower (office visits are covered after a $25 copay). If your primary care physician refers you to receive care in the Boston Medical Center Preferred Expanded Circle network, you will receive 70% coverage for most services (based on reasonable and customary charges). You pay the remaining 30% (your coinsurance)  and any charges above reasonable and customary limits. Once your 30% coinsurance reaches the out-of-pocket limit of $2,500 (individual coverage) or $5,000 (family coverage), the plan will pay 100% of covered expenses for the rest of the calendar year. If  you do not receive a referral, you will pay a higher copayment or coinsurance amount, depending on where you receive your care.

If you are admitted to a non-network (i.e., one not in the Inner Circle) hospital for emergency care, you or someone on your behalf must notify the plan within 48 hours of the admission. If Boston Medical Center Preferred is not notified, you will pay a higher copayment or coinsurance amount, depending on where you receive your care.

As part of the benefit approval process, your hospital stay will be monitored and your physician and health plan will work closely together to arrange any necessary patient care after discharge.

Certain expenses do not apply toward your out-of-pocket limit, including: