Anthem Bronze Pathway X Enhanced HMO 35% for HSA - 96751NH0150015 Health Insurance Plan

Matthew Thornton Hlth Plan(Anthem BCBS) health insurance plan with the Plan ID 96751NH0150015. The plan is called Anthem Bronze Pathway X Enhanced HMO 35% for HSA.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 63.64% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 36.36% of the costs of all covered benefits (according to the Issuer).

Health Insurance Plan ID 96751NH0150015
Health Insurance Plan Year 2023
State New Hampshire
Health Insurance Issuer Matthew Thornton Hlth Plan(Anthem BCBS)
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 96751NH0150015-00
Provider Network(s) ['NHN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers New Hampshire All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 96751NH0150015-00

Standard On Exchange Plan - 96751NH0150015-01

Open to Indians below 300% FPL - 96751NH0150015-02

Open to Indians above 300% FPL - 96751NH0150015-03

Last Plan Update Date Tue, 09 May 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan, 96751NH0150015-00

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

35.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

35.00% Coinsurance after deductible

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

35.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

35.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Year

YES

35.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

35.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

35.00% Coinsurance after deductible

100.00%
Dialysis
YES

35.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Coverage for external breast prostheses is limited to 2 prostheses per breast, per Calendar Year. Coverage for post-mastectomy bras is limited to 3 bras per Member, per Calendar Year

YES

35.00% Coinsurance after deductible

100.00%
Emergency Room Services

Emergency Room Facility Fee Cost Share is waived if member is admitted to the hospital.

YES

$500.00 Copay after deductible, 35.00% Coinsurance after deductible

$500.00 Copay after deductible, 35.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Non-emergency ambulance/transportation out of network is not covered unless authorized. Authorized out of network is limited to $50,000 per occurrence.

YES

35.00% Coinsurance after deductible

35.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

Cost share is for a 30 day supply.? 90 day supply is available with additional cost shares.

YES

Tier 1: 35.00% Coinsurance after deductible

Tier 2: 50.00% Coinsurance after deductible

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Year

Limit is combined across professional visits and outpatient facilities. Benefit limit does not apply when related to Autism.

YES

35.00% Coinsurance after deductible

100.00%
Hearing Aids
YES

35.00% Coinsurance after deductible

100.00%
Home Health Care Services
YES

35.00% Coinsurance after deductible

100.00%
Hospice Services

Hospice Beareavement is not covered.

YES

35.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

35.00% Coinsurance after deductible

100.00%
Infertility Treatment

Exclusions: The benefits do not include artificial insemination (AI) services or assisted reproductive technologies (ART) services or the diagnostic tests and Drugs to support AI or ART services. Examples of ART include in-vitro fertilization, zygote intrafallopian transfer (ZIFT), or gamete intrafallopian transfer (GIFT).

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

35.00% Coinsurance after deductible

100.00%
Infusion Therapy
YES

35.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

35.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

35.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

35.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

35.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Member coinsurance will not exceed the Primary Care Provider copay.

YES

35.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs

Cost share is for a 30 day supply.? 90 day supply is available with additional cost shares.

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 55.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

35.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)

You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.

YES

35.00% Coinsurance after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

35.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Year

Limit is combined across professional visits and outpatient facilities. Benefit limit does not apply when related to Autism.

YES

35.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

35.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Cost share is for a 30 day supply.? 90 day supply is available with additional cost shares.

YES

Tier 1: 35.00% Coinsurance after deductible

Tier 2: 50.00% Coinsurance after deductible

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

You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.

YES

35.00% Coinsurance after deductible

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

35.00% Coinsurance after deductible

100.00%
Radiation
YES

35.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

35.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

Exclusions: Occupational therapy does not include recreational or vocational therapies, such as hobbies, arts and crafts.

Limit is combined across professional visits and outpatient facilities. Benefit limit does not apply when related to Autism.

YES

35.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Limit is combined across professional visits and outpatient facilities. Benefit limit does not apply when related to Autism.

YES

35.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

This Plan covers a complete eye exam and if needed, dilation.

YES

No Charge

100.00%
Routine Foot Care

Covered if medically necessary for illness or injury.

YES

35.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Limit: 100.0 Days per Year

Exclusions: Custodial Care is not a Covered Service.

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

35.00% Coinsurance after deductible

100.00%
Specialist Visit

You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.

YES

35.00% Coinsurance after deductible

100.00%
Specialty Drugs

Cost share is for a 30 day supply.

YES

Tier 1: 40.00% Coinsurance after deductible

Tier 2: 55.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

35.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Member coinsurance will not exceed the Primary Care Provider copay.

YES

35.00% Coinsurance after deductible

100.00%
Transplant

Limited to a maximum of the 10 best matched donors, identified by an authorized registry.

YES

35.00% 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

35.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$50.00 Copay after deductible, 35.00% Coinsurance after deductible

$50.00 Copay after deductible, 35.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care

Benefits are covered under preventive care.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

35.00% Coinsurance after deductible

100.00%

Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan Variant 96751NH0150015-00 Attributes

Plan Attribute Value
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze 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
EHB Percent of Total Premium 1
First Tier Utilization 51%
Formulary ID NHF005
Formulary URL URL
HIOS Product ID 96751NH015
Import Date 5/9/2023 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 63.64%
Issuer ID 96751
Issuer Marketplace Marketing Name Anthem Blue Cross and Blue Shield
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
Multiple In Network Tiers Yes
National Network No
Network ID NHN001
Out of Country Coverage No
Out of Country Coverage Description Urgent/Emergency Coverage Only
Out of Service Area Coverage No
Out of Service Area Coverage Description TRAD/PAR network
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 96751NH0150015-00
Plan Marketing Name Anthem Bronze Pathway X Enhanced HMO 35% for HSA
Plan Type HMO
Plan Variant Marketing Name Anthem Bronze Pathway X Enhanced HMO 35% for HSA
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,400
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $6,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,400
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 49%
Service Area ID NHS001
Source Name SERFF
Plan ID 96751NH0150015
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 35.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $12000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $6000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $6,000
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 35.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $12000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $6000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $6,000
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 $14800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7400 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,400
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $14800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $7400 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $7,400
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan, 96751NH0150015

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Anthem Bronze Pathway X Enhanced HMO 35% for HSA, 96751NH0150015 Health Insurance Plan, 96751NH0150015

  • Does Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan, 96751NH0150015 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (96751NH0150015) Health Insurance Plan, Variant (96751NH0150015-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management

    Does (96751NH0150015) Health Insurance Plan, Variant (96751NH0150015-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: Urgent/Emergency Coverage Only

    Does (96751NH0150015) Health Insurance Plan, Variant (96751NH0150015-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: TRAD/PAR network

    Does (96751NH0150015) Health Insurance Plan, Variant (96751NH0150015-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management

    Does Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan, Variant (96751NH0150015-00) offer Disease Management Programs for Asthma?

    Yes, the Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan Variant 96751NH0150015-00 offers Disease Management Program for Asthma.

    Does Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan, Variant (96751NH0150015-00) offer Disease Management Programs for Heart disease?

    Yes, the Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan Variant 96751NH0150015-00 offers Disease Management Program for Heart disease.

    Does Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan, Variant (96751NH0150015-00) offer Disease Management Programs for Depression?

    Yes, the Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan Variant 96751NH0150015-00 offers Disease Management Program for Depression.

    Does Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan, Variant (96751NH0150015-00) offer Disease Management Programs for Diabetes?

    Yes, the Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan Variant 96751NH0150015-00 offers Disease Management Program for Diabetes.

    Does Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan, Variant (96751NH0150015-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan Variant 96751NH0150015-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan, Variant (96751NH0150015-00) offer Disease Management Programs for Low back pain?

    Yes, the Anthem Bronze Pathway X Enhanced HMO 35% for HSA Health Insurance Plan Variant 96751NH0150015-00 offers Disease Management Program for Low back pain.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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