NH Local HMO Silver 5000 Standard - 59025NH0370085 Health Insurance Plan
Harvard Pilgrim Health Care of NE health insurance plan with the Plan ID 59025NH0370085. The plan is called NH Local HMO Silver 5000 Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.09% (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 26.91% 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 | 59025NH0370085 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| 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 | 59025NH0370085-04 | ||||||||||||||||||
| Provider Network(s) | STANDARD | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 59025NH0370085-00 Standard On Exchange Plan - 59025NH0370085-01 Open to Indians below 300% FPL - 59025NH0370085-02 Open to Indians above 300% FPL - 59025NH0370085-03 73% AV Silver Plan - 59025NH0370085-04 |
||||||||||||||||||
| Last Plan Update Date | Thu, 03 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of NH Local HMO Silver 5000 Standard Health Insurance Plan, 59025NH0370085-04
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Coverage is not provided for abortion, except when the life of the mother is endangered or when the pregnancy is a result of rape or incest. |
NO | ||
| Accidental Dental
Coverage for treatment resulting from accidental injury to sound natural teeth and gums. Repairs to teeth with damage resulting from normal activities of daily living or extraordinary use of the teeth is not covered. |
YES | $40.00 |
100.00% |
| Acupuncture
There is no visit limit for Acupuncture, however member cost sharing applies. |
YES | $40.00 |
100.00% |
| Allergy Testing
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Applied Behavior Analysis Based Therapies
|
YES | $40.00 |
100.00% |
| Bariatric Surgery
In order to receive coverage for bariatric surgery, care must be received from a designated center of excellence. To verify a provider's status, refer to the online provider directory. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
Coverage is not provided for adult dental care. |
NO | ||
| Basic Dental Care - Child
Coverage is not provided for pediatric dental care. |
NO | ||
| Bone Marrow Transplant
Provided in a Hospital- Acute Inpatient setting. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
Provided in a Hospital-Outpatient setting. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
There is no visit limit for Chiropractic Care, however member cost sharing applies. |
YES | $40.00 |
100.00% |
| Convenience Care Clinic
|
YES | $40.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
48 Hour Minimum Stay-Vaginal; 96 Hour Minimum Stay-Cesarean. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Dental Anesthesia
Provided in a Hospital- Acute Inpatient setting. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Coverage is not provided for pediatric dental care. |
NO | ||
| Diabetes Care Management
|
YES | $40.00 |
100.00% |
| Diabetes Education
The Plan covers outpatient self-management education and training for the treatment of diabetes, including medical nutrition therapy services, used to diagnose or treat insulin-dependent diabetes, non-insulin dependent diabetes, or gestational diabetes. Services must be provided on an individual basis and be provided by a Plan Provider |
YES | $80.00 |
100.00% |
| Dialysis
Plan approval required for dialysis services when temporarily traveling outside of the state where you live. Such coverage is only provided for up to 30 days per calendar year. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
One breast pump per birth (rented or purchased) |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Early Intervention Services
Limit: 40.0 Visit(s) per Year For Members under the age of 3, coverage is available for services rendered by occupational therapists, physical therapists, speech-language pathologists and clinical social workers |
YES | No Charge |
100.00% |
| Emergency Room Services
Emergency room copayments are waived when a member is directly admitted to the hospital. |
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
If you have a Medical Emergency, your Plan covers ambulance transport to the nearest Hospital that can provide care. |
YES | 40.00% Coinsurance after deductible |
40.00% 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 either (a) 1 pair of standard or basic eyeglass frames and lenses or (b) 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 | 40.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Certain preventative services are covered at no cost to the member. See a complete list at harvardpilgrim.org Coverage for some generic OTC medications is available at tier 1 Rx cost sharing. You can use the drug lookup tool at harvardpilgrim.com/rx to search the formulary for OTC medications you may be taking. Members save money by obtaining a 90-day supply of tier 1 maintenance medications through our mail order pharmacy. |
YES | $20.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit. |
YES | $40.00 |
100.00% |
| Hearing Aids
Coverage is limited to 1 hearing aid per hearing-impaired ear when medically necessary. |
YES | 50.00% |
100.00% |
| Home Health Care Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Provided in a Hospice-Outpatient setting. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their imaging services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Covered benefits include consultation, evaluation and laboratory testing. Coverage is also provided for services to treat underlying medical conditions that may cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). Infertility drugs and treatment such as therapeutic donor insemination and advanced reproductive technologies are excluded from coverage. |
NO | ||
| Infusion Therapy
Provided in a Hospital-Outpatient setting. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inherited Metabolic Disorders - PKU
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Rehabilitation Services
Limit: 100.0 Days per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their lab services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Low Protein Foods
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Major Dental Care - Adult
Coverage is not provided for adult dental care. |
NO | ||
| Major Dental Care - Child
Coverage is not provided for pediatric dental care. |
NO | ||
| Mental/Behavioral Health Inpatient Services
Coverage is provided for inpatient mental health, substance use disorder and detoxification services. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Coverage is provided for care provided in-person, virtually, through secure digital messaging and through e-visits. |
YES | $40.00 |
100.00% |
| Non-Preferred Brand Drugs
Members may have a lower total out of pocket cost when they obtain a 90-day supply of maintenance medications through our mail order pharmacy. |
YES | $80.00 Copay after deductible |
100.00% |
| Nutritional Counseling
|
YES | $40.00 |
100.00% |
| Off Label Prescription Drugs
|
YES | $350.00 Copay after deductible |
100.00% |
| Orthodontia - Adult
Coverage is not provided for adult dental care. |
NO | ||
| Orthodontia - Child
Coverage is not provided for pediatric dental care. |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit. |
YES | $40.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Members save money by obtaining a 90-day supply of tier 2 maintenance medications through our mail order pharmacy. |
YES | $40.00 |
100.00% |
| Prenatal and Postnatal Care
Routine Prenatal and Postnatal Care are covered in full. |
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
Certain preventive services as defined in Federal law are covered with no Out-Of-Pocket cost to member when provided by a Plan Provider. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
You can access medical urgent care with $0 cost sharing from our virtual provider, Doctor on Demand. Visit doctorondemand.com/harvardpilgrim for more information. |
YES | $40.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Coveage is provided for (a) the least costly prosthetic device adequate to allow you to perform Activities of Daily Living. Activities of Daily Living do not include special functions needed for occupational purposes or sports; and (b) one item of each type of prosthetic device. No back-up items or items that serve a duplicate purpose are covered. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Radiation
Provided in a Hospital-Outpatient setting. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Provided in a Hospital- Acute Inpatient setting. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit. |
YES | $40.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Year Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit. |
YES | $40.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per 2 Years Adults are covered for one routine eye exam every 2 years. |
YES | $40.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Members under the age of 19 are covered for one routine eye exam every year. |
YES | $40.00 |
100.00% |
| Routine Foot Care
Excluded, except for preventive foot care for members with diabetes or systemic circulatory diseases. |
YES | $80.00 |
100.00% |
| Skilled Nursing Facility
Limit: 100.0 Days per Year Coverage limited to 100 days per year. Custodial or Long Term Care is not covered. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
You can access medical urgent care with $0 cost sharing from our virtual provider, Doctor on Demand. Visit doctorondemand.com/harvardpilgrim for more information. |
YES | $80.00 |
100.00% |
| Specialty Drugs
Members may have a lower total out of pocket cost when they obtain a 90-day supply of maintenance medications through our mail order pharmacy. |
YES | $350.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Coverage is provided for inpatient mental health, substance use disorder and detoxification services. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Coverage is provided for care provided in-person, virtually, through secure digital messaging and through e-visits. |
YES | $40.00 |
100.00% |
| Transplant
Provided in a Hospital- Acute Inpatient setting. |
YES | 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 | 40.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
Urgent care centers can be both freestanding and hospital-based. Receiving care from freestanding urgent care clinics often has lower member out of pocket cost. To locate freestanding urgent care clinics in our network, search for 'Urgent Care Center' provider type in the online provider directory. |
YES | $60.00 |
100.00% |
| Weight Loss Programs
There is no coverage for weight loss programs. Members can get reimbursement for a fitness club membership or virtual fitness class subscription. Learn more by visiting harvardpilgrim.org/fitnessreimbursement. Through our partner, WebMD, program members can earn rewards for participating in a variety of informative and interactive activities that supports all aspects of well-being, including healthy eating, physical activity, financial wellness, mindfulness and meditation, self-care and stress management This program is a subscriber-only program and participants can earn up to $120 in rewards per year. |
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| Wigs
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| X-rays and Diagnostic Imaging
Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their imaging services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information. |
YES | 40.00% Coinsurance after deductible |
100.00% |
NH Local HMO Silver 3000 Standard CSR73 Health Insurance Plan Variant 59025NH0370085-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7309378231069821 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 73% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| 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 | 0.997181 |
| First Tier Utilization | 100% |
| Formulary ID | NHF014 |
| Formulary URL | URL |
| HIOS Product ID | 59025NH037 |
| Import Date | 2024-10-03 20:01:44 |
| 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 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 | No |
| National Network | No |
| Network ID | NHN002 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 59025NH0370085-04 |
| Plan Marketing Name | NH Local HMO Silver 5000 Standard |
| Plan Type | HMO |
| Plan Variant Marketing Name | NH Local HMO Silver 3000 Standard CSR73 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,400 |
| SBC Scenario, Having a Baby, Copayment | $50 |
| SBC Scenario, Having a Baby, Deductible | $3,000 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,000 |
| SBC Scenario, Having Diabetes, Deductible | $1,100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,200 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NHS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | A Referral is Needed for all Specialist except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers. |
| Plan ID | 59025NH0370085 |
| 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 | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $6000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,000 |
| 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 | $12800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,400 |
| 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 | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of NH Local HMO Silver 5000 Standard Health Insurance Plan, 59025NH0370085
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about NH Local HMO Silver 5000 Standard, 59025NH0370085 Health Insurance Plan, 59025NH0370085
-
Does NH Local HMO Silver 5000 Standard Health Insurance Plan, 59025NH0370085 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (59025NH0370085) Health Insurance Plan, Variant (59025NH0370085-04) offer Disease Management Programs?
Does (59025NH0370085) Health Insurance Plan, Variant (59025NH0370085-04) have Out Of Country Coverage?
Does (59025NH0370085) Health Insurance Plan, Variant (59025NH0370085-04) have Out of Service Area Coverage?
Does (59025NH0370085) Health Insurance Plan, Variant (59025NH0370085-04) offer Disease Management Programs?
Does NH Local HMO Silver 3000 Standard CSR73 Health Insurance Plan, Variant (59025NH0370085-04) offer Disease Management Programs for Asthma?
Does NH Local HMO Silver 3000 Standard CSR73 Health Insurance Plan, Variant (59025NH0370085-04) offer Disease Management Programs for Heart disease?
Does NH Local HMO Silver 3000 Standard CSR73 Health Insurance Plan, Variant (59025NH0370085-04) offer Disease Management Programs for Depression?
Does NH Local HMO Silver 3000 Standard CSR73 Health Insurance Plan, Variant (59025NH0370085-04) offer Disease Management Programs for Diabetes?
Does NH Local HMO Silver 3000 Standard CSR73 Health Insurance Plan, Variant (59025NH0370085-04) offer Disease Management Programs for High blood pressure & high cholesterol?
Does NH Local HMO Silver 3000 Standard CSR73 Health Insurance Plan, Variant (59025NH0370085-04) offer Disease Management Programs for Low back pain?
Does NH Local HMO Silver 3000 Standard CSR73 Health Insurance Plan, Variant (59025NH0370085-04) offer Disease Management Programs for Pregnancy?
Does NH Local HMO Silver 3000 Standard CSR73 Health Insurance Plan, Variant (59025NH0370085-04) 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