NH Local Choice HMO Silver 2500 - 59025NH0370069 Health Insurance Plan
Harvard Pilgrim Health Care of NE health insurance plan with the Plan ID 59025NH0370069. The plan is called NH Local Choice HMO Silver 2500.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.11% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.89% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.13% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.87% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 59025NH0370069 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New Hampshire | ||||||||||||||||||
| Health Insurance Issuer | Harvard Pilgrim Health Care of NE | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 59025NH0370069-00 | ||||||||||||||||||
| Provider Network(s) | STANDARD PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 59025NH0370069-00 Standard On Exchange Plan - 59025NH0370069-01 Open to Indians below 300% FPL - 59025NH0370069-02 Open to Indians above 300% FPL - 59025NH0370069-03 73% AV Silver Plan - 59025NH0370069-04 |
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| Last Plan Update Date | Tue, 24 Oct 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of NH Local Choice HMO Silver 2500 Health Insurance Plan, 59025NH0370069-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Exclusions: No coverage for services to treat sound, natural teeth and gums resulting from an accidental injury received after three months of the date of injury. |
YES | $40.00 |
100.00% |
| Acupuncture
|
YES | $40.00 |
100.00% |
| Allergy Testing
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Applied Behavior Analysis Based Therapies
|
YES | $40.00 |
100.00% |
| Bariatric Surgery
Provided in a Hospital- Acute Inpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Bone Marrow Transplant
Provided in a Hospital- Acute Inpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
Provided in a Hospital-Outpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
YES | Tier 1: $40.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Convenience Care Clinic
|
YES | $40.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Dental Anesthesia
Provided in a Hospital- Acute Inpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | Tier 1: $40.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Diabetes Education
|
YES | Tier 1: $80.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Dialysis
Provided in a Hospital-Outpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Early Intervention Services
Limit: 40.0 Visit(s) per Year For Members under the age of 3 |
YES | No Charge |
100.00% |
| Emergency Room Services
|
YES | $500.00 Copay after deductible |
$500.00 Copay after deductible |
| Emergency Transportation/Ambulance
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Each Dependent under the age of 19 is covered every 12 months for eyeglass frames and lenses, first order of contact lenses, or a 6 month supply of disposable contact lenses. Limits apply, refer to the Schedule of Benefits. |
YES | 50.00% |
50.00% |
| Gender Affirming Care
Provided in a Hospital- Acute Inpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | $10.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: No visit limits for physical, occupational and speech therapy when it is for the treatment of Autism Spectrum Disorders. Physical, Occupational, and Speech Therapy are limited to 60 visits per year combined. |
YES | Tier 1: $60.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
YES | 50.00% |
100.00% |
| Home Health Care Services
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Provided in a Hospice-Outpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Provided in a Hospital-Outpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorders - PKU
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Rehabilitation Services
Limit: 100.0 Days per Year |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Low Protein Foods
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $40.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | Tier 1: $40.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Off Label Prescription Drugs
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | Tier 1: $60.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: No visit limits for physical, occupational and speech therapy when it is for the treatment of Autism Spectrum Disorders. Physical, Occupational, and Speech Therapy are limited to 60 visits per year combined. |
YES | Tier 1: $60.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $100.00 |
100.00% |
| Prenatal and Postnatal Care
Routine Prenatal and Postnatal Care are covered in full. |
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | Tier 1: $40.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Radiation
Provided in a Hospital-Outpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Provided in a Hospital- Acute Inpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Exclusions: No visit limits for physical, occupational and speech therapy when it is for the treatment of Autism Spectrum Disorders. Physical, Occupational, and Speech Therapy are limited to 60 visits per year combined. |
YES | Tier 1: $60.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Year Exclusions: No visit limits for physical, occupational and speech therapy when it is for the treatment of Autism Spectrum Disorders. Physical, Occupational, and Speech Therapy are limited to 60 visits per year combined. |
YES | Tier 1: $60.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per 2 Years For Members age 19 and over |
YES | Tier 1: $40.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year For Members under the age of 19 |
YES | Tier 1: $40.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Routine Foot Care
Exclusions: Excluded for all diagnosis, except for the treatment of diabetes. |
YES | Tier 1: $80.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Skilled Nursing Facility
Limit: 100.0 Days per Year |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | Tier 1: $80.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Specialty Drugs
Exclusions: Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $40.00 |
100.00% |
| Transplant
Provided in a Hospital- Acute Inpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: No dental care is covered for the treatment of TMJ. Limited to the following; one lifetime consultation, PT and OT, and medically necessary surgical treatment. Provided in a Surgery-Outpatient setting. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $50.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| Wigs
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
NH Local Choice HMO Silver 2500 Health Insurance Plan Variant 59025NH0370069-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.711314166251075 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9967108541812021 |
| First Tier Utilization | 70% |
| Formulary ID | NHF012 |
| Formulary URL | URL |
| HIOS Product ID | 59025NH037 |
| Import Date | 2023-10-24 20:01:56 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 70.11% |
| Issuer ID | 59025 |
| Issuer Marketplace Marketing Name | Harvard Pilgrim Health Care |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | NHN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 59025NH0370069-00 |
| Plan Marketing Name | NH Local Choice HMO Silver 2500 |
| Plan Type | HMO |
| Plan Variant Marketing Name | NH Local Choice HMO Silver 2500 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,000 |
| SBC Scenario, Having a Baby, Copayment | $60 |
| SBC Scenario, Having a Baby, Deductible | $2,500 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,800 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,200 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 30% |
| Service Area ID | NHS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers. |
| Plan ID | 59025NH0370069 |
| State Code | NH |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $5000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,500 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $14000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $7000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $7,000 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of NH Local Choice HMO Silver 2500 Health Insurance Plan, 59025NH0370069
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about NH Local Choice HMO Silver 2500, 59025NH0370069 Health Insurance Plan, 59025NH0370069
-
Does NH Local Choice HMO Silver 2500 Health Insurance Plan, 59025NH0370069 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (59025NH0370069) Health Insurance Plan, Variant (59025NH0370069-00) offer Disease Management Programs?
Does (59025NH0370069) Health Insurance Plan, Variant (59025NH0370069-00) have Out Of Country Coverage?
Does (59025NH0370069) Health Insurance Plan, Variant (59025NH0370069-00) have Out of Service Area Coverage?
Does (59025NH0370069) Health Insurance Plan, Variant (59025NH0370069-00) offer Disease Management Programs?
Does NH Local Choice HMO Silver 2500 Health Insurance Plan, Variant (59025NH0370069-00) offer Disease Management Programs for Asthma?
Does NH Local Choice HMO Silver 2500 Health Insurance Plan, Variant (59025NH0370069-00) offer Disease Management Programs for Heart disease?
Does NH Local Choice HMO Silver 2500 Health Insurance Plan, Variant (59025NH0370069-00) offer Disease Management Programs for Depression?
Does NH Local Choice HMO Silver 2500 Health Insurance Plan, Variant (59025NH0370069-00) offer Disease Management Programs for Diabetes?
Does NH Local Choice HMO Silver 2500 Health Insurance Plan, Variant (59025NH0370069-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does NH Local Choice HMO Silver 2500 Health Insurance Plan, Variant (59025NH0370069-00) offer Disease Management Programs for Low back pain?
Does NH Local Choice HMO Silver 2500 Health Insurance Plan, Variant (59025NH0370069-00) offer Disease Management Programs for Pregnancy?
Does NH Local Choice HMO Silver 2500 Health Insurance Plan, Variant (59025NH0370069-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API