WellSense Clarity NH Silver 5800 + $0 Rx List + 24/7 Nurse Advice - 13219NH0010003 Health Insurance Plan
Boston Medical Center Health Plan, Inc. health insurance plan with the Plan ID 13219NH0010003. The plan is called WellSense Clarity NH Silver 5800 + $0 Rx List + 24/7 Nurse Advice.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.14% (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 26.86% 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 | 13219NH0010003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | New Hampshire | ||||||||||||||||||
| Health Insurance Issuer | Boston Medical Center Health Plan, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 13219NH0010003-04 | ||||||||||||||||||
| Provider Network(s) | PREFERRED NON-PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 13219NH0010003-00 Standard On Exchange Plan - 13219NH0010003-01 Open to Indians below 300% FPL - 13219NH0010003-02 Open to Indians above 300% FPL - 13219NH0010003-03 73% AV Silver Plan - 13219NH0010003-04 |
||||||||||||||||||
| Last Plan Update Date | Fri, 18 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of WellSense Clarity NH Silver 5800 + $0 Rx List + 24/7 Nurse Advice Health Insurance Plan, 13219NH0010003-04
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
No Coverage except limited to therapeutic coverage (only in case of rape, incest, or health of mother) |
NO | ||
| Accidental Dental
Benefits are available for dental work that is Medically Necessary due to an accidental injury to sound natural teeth and gums when the course of treatment for the accidental injury is received or authorized within 3 months of the date of the injury. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Covered only as part of SUD services including detoxification. |
YES | $25.00 |
100.00% |
| Allergy Testing
|
YES | $50.00 |
100.00% |
| Bariatric Surgery
Benefits are available for bariatric surgery that is Medically Necessary for the treatment of diseases and ailments caused by or resulting from obesity or morbid obesity. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
Members must purchase a separate dental plan for coverage of routine and non-routine dental services. |
NO | ||
| Basic Dental Care - Child
Members must purchase a separate dental plan for coverage of routine and non-routine dental services. |
NO | ||
| Chemotherapy
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year |
YES | $50.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Members must purchase a separate dental plan for coverage of routine and non-routine dental services. |
NO | ||
| Diabetes Education
|
YES | $0.00 Copay after deductible |
100.00% |
| Dialysis
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Procedure |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | $20.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year 20 visits each per PT, OT, ST. Habilitative services include 'services that help you keep, learn or improve skills and functioning for daily living.' However, though definition includes the term 'keep,' the plan excludes coverage of 'Maintenance Therapy,' defined as 'Treatment given when no further gains are clear or likely to occur. Maintenance therapy includes care that helps you keep your current level of function and prevents loss of that function, but does not result in any change for the better.' |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per Procedure Benefits are available for one hearing aid per ear each time a hearing aid prescription changes. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy, endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
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% |
| Laboratory Outpatient and Professional Services
|
YES | $25.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
Members must purchase a separate dental plan for coverage of routine and non-routine dental services. |
NO | ||
| Major Dental Care - Child
Members must purchase a separate dental plan for coverage of routine and non-routine dental services. |
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services [e.g., consider including a non-exhaustive list of examples] may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $25.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $80.00 Copay after deductible |
100.00% |
| Nutritional Counseling
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
Members must purchase a separate dental plan for coverage of routine and non-routine dental services. |
NO | ||
| Orthodontia - Child
Members must purchase a separate dental plan for coverage of routine and non-routine dental services. |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $25.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year 20 visits each per PT, OT, ST. Rehabilitation |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $40.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $25.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
This Plan covers a complete eye exam with dilation, as needed. |
YES | $50.00 |
100.00% |
| Routine Foot Care
Medically Necessary Routine foot care for members with diabetes or systemic circulatory disease or peripheral artery disease. |
YES | $50.00 |
100.00% |
| Skilled Nursing Facility
Limit: 100.0 Days per Year When you require Inpatient skilled nursing and related services for convalescent and rehabilitative care, Covered Services are available if the Facility is licensed or certified under state law as a Skilled Nursing Facility. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $50.00 |
100.00% |
| Specialty Drugs
|
YES | $350.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services [e.g., consider including a non-exhaustive list of examples] may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $25.00 |
100.00% |
| Transplant
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. |
YES | $50.00 |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $50.00 |
$50.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Covered under preventive care. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 40.00% Coinsurance after deductible |
100.00% |
WellSense Clarity NH Silver 5800 Core 3 + $0 Rx List + 24/7 Nurse Advice Health Insurance Plan Variant 13219NH0010003-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.731374630703307 |
| 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 | Not Applicable |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | NHF005 |
| Formulary URL | URL |
| HIOS Product ID | 13219NH001 |
| Import Date | 2024-10-18 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? | No |
| Issuer ID | 13219 |
| Issuer Marketplace Marketing Name | WellSense Health Plan |
| 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 | NHN001 |
| Out of Country Coverage | No |
| Out of Country Coverage Description | Emergency and urgent services only but not to return members to the service area after an emergency or urgent condition is stabilized |
| Out of Service Area Coverage | No |
| Out of Service Area Coverage Description | Emergency and urgent services only but not to return members to the service area after an emergency or urgent condition is stabilized |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 13219NH0010003-04 |
| Plan Marketing Name | WellSense Clarity NH Silver 5800 + $0 Rx List + 24/7 Nurse Advice |
| Plan Type | HMO |
| Plan Variant Marketing Name | WellSense Clarity NH Silver 5800 Core 3 + $0 Rx List + 24/7 Nurse Advice |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,700 |
| SBC Scenario, Having a Baby, Copayment | $20 |
| SBC Scenario, Having a Baby, Deductible | $5,200 |
| SBC Scenario, Having a Baby, Limit | $80 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,700 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NHS001 |
| Source Name | SERFF |
| Plan ID | 13219NH0010003 |
| State Code | NH |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $14200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $7100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $7,100 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $10400 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $5200 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $5,200 |
| 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 | $10400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,200 |
| 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 | $14200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,100 |
| 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 | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of WellSense Clarity NH Silver 5800 + $0 Rx List + 24/7 Nurse Advice Health Insurance Plan, 13219NH0010003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about WellSense Clarity NH Silver 5800 + $0 Rx List + 24/7 Nurse Advice, 13219NH0010003 Health Insurance Plan, 13219NH0010003
-
Does WellSense Clarity NH Silver 5800 + $0 Rx List + 24/7 Nurse Advice Health Insurance Plan, 13219NH0010003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (13219NH0010003) Health Insurance Plan, Variant (13219NH0010003-04) have Out Of Country Coverage?
Does (13219NH0010003) Health Insurance Plan, Variant (13219NH0010003-04) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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