Anthem Gold Pathway X HMO 500/25%/7000 - 96751NH0160065 Health Insurance Plan

Matthew Thornton Hlth Plan(Anthem BCBS) health insurance plan with the Plan ID 96751NH0160065. The plan is called Anthem Gold Pathway X HMO 500/25%/7000.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.63% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.37% 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 83.27% (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 16.73% 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 96751NH0160065
Health Insurance Plan Year 2023
State New Hampshire
Health Insurance Issuer Matthew Thornton Hlth Plan(Anthem BCBS)
Plan Formulary Description URL Formulary URL
Health Insurance Plan Variant 96751NH0160065-00
Provider Network(s) ['NHN003']
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 - 96751NH0160065-00

Standard On Exchange Plan - 96751NH0160065-01

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

Benefits of Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan, 96751NH0160065-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited

Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

100.00%
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. Cost share is driven by provider/setting.

YES

$45.00

100.00%
Acupuncture

Limit: 20.0 Visit(s) per Benefit Period

Cost share driven by Provider setting. Limit is combined across professional visits and outpatient facilities.

YES

$20.00

100.00%
Allergy Testing
YES

25.00% 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. Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

25.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 36.0 Visit(s) per Benefit Period

Benefit limit does not apply to Osteopathic manipulative treatment. Cost share driven by Provider setting. Limit is combined across professional visits and outpatient facilities.

YES

$20.00

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

25.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Limit: 2.0 Visit(s) per Benefit Period

Limit is combined across professional visits and outpatient facilities.

YES

No Charge after deductible

100.00%
Diabetes Education

Cost share is driven by Provider setting.

YES

$45.00

100.00%
Dialysis
YES

25.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

25.00% Coinsurance after deductible

100.00%
Emergency Room Services

Emergency Room copay is waived if admitted to hospital.

YES

$350.00 Copay after deductible

$350.00 Copay after deductible
Emergency Transportation/Ambulance
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

Eye glasses or Contact Lenses are covered once per benefit period for INN Services.

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

Members can choose to receive a 90-day supply at retail pharmacies. When there is a copay, the copay is three times the standard retail copayment.

YES

Tier 1: $25.00

Tier 2: $35.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Benefit Period

Exclusions: The plan excludes coverage of Maintenance Therapy, defined as a 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.

Limited to 60 combined visits for Physical, Occupational, and Speech Therapy benefit. Cost share driven by Provider setting. Limit is combined across professional visits and outpatient.

YES

$20.00

100.00%
Hearing Aids
YES

25.00% Coinsurance after deductible

100.00%
Home Health Care Services

Coverage excludes Private Duty nursing services.

YES

25.00% Coinsurance after deductible

100.00%
Hospice Services

Cost share driven by Provider setting.

YES

No Charge after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

Cost share is driven by Provider setting.

YES

25.00% 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). Cost share is driven by Provider setting.

YES

25.00% Coinsurance after deductible

100.00%
Infusion Therapy
YES

25.00% Coinsurance after deductible

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

Limited to 100 days per benefit period for Inpatient Rehabilitation services. Limit applies to Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis).

YES

25.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services

Limited to 100 days per benefit period for Inpatient Rehabilitation services. Limit applies to Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis).

YES

25.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Cost share is driven by Provider setting.

YES

No Charge

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

Cost share driven by Provider setting.

YES

$20.00

100.00%
Non-Preferred Brand Drugs

Members can choose to receive a 90-day supply at retail pharmacies.

YES

Tier 1: 30.00%

Tier 2: 40.00%

100.00%
Nutritional Counseling

Covered under preventive guidelines and for diabetes.

YES

$20.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
YES

50.00% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$20.00

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

Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Benefit Period

Limited to 60 combined visits for Physical, Occupational, and Speech Therapy benefit. Cost share driven by Provider setting. Limit is combined across professional visits and outpatient.

YES

$20.00

100.00%
Outpatient Surgery Physician/Surgical Services

Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Members can choose to receive a 90-day supply at retail pharmacies. When there is a copay, the copay is three times the standard retail copayment.

YES

Tier 1: $80.00

Tier 2: $90.00

100.00%
Prenatal and Postnatal Care

In network preventive prenatal and postnatal services are covered at 100%.

YES

25.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

PCP copay may be discounted depending upon provider selected.

YES

$20.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

25.00% Coinsurance after deductible

100.00%
Radiation
YES

25.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Cost share driven by Provider setting.

YES

25.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 60.0 Visit(s) per Benefit Period

Limited to 60 combined visits for rehabilitative Physical, Occupational, and Speech Therapy benefits. Cost share driven by Provider setting. Limit is combined across professional visits and outpatient facilities.

YES

$20.00

100.00%
Rehabilitative Speech Therapy

Limit: 60.0 Visit(s) per Benefit Period

Limited to 60 combined visits for rehabilitative Physical, Occupational, and Speech Therapy benefits. Cost share driven by Provider setting. Limit is combined across professional visits and outpatient facilities.

YES

$20.00

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

Limit: 1.0 Visit(s) per Benefit Period

Eye exams are covered once per benefit period for INN Services.

YES

$20.00

100.00%
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Benefit Period

Eye exams are covered once per benefit period for INN Services. ?

YES

No Charge

100.00%
Routine Foot Care

Exclusions: The following services are excluded from routine foot care. Cutting or removing corns and calluses, trimming nails, cleaning and preventive foot care including but not limited to; cleaning and soaking the feet, applying skin creams to care for skin tone and other services that are given when there is not an illness, injury or symptom involving the foot.

Covered if medically necessary for illness or injury. Cost share is driven by Provider setting.

YES

$45.00

100.00%
Skilled Nursing Facility

Limit: 100.0 Days per Benefit Period

Limited to 100 days per benefit period for Inpatient Rehabilitation services.

YES

25.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$45.00

100.00%
Specialty Drugs
YES

Tier 1: 40.00%

Tier 2: 50.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

Cost share driven by Provider setting.

YES

$20.00

100.00%
Transplant

Exclusions: Meals relative to transportation and lodging are excluded.

YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Coverage includes TMJ surgery and limited non-surgical treatment. Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.

YES

25.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities

Costs may vary by site of service.

YES

$100.00

$100.00
Weight Loss Programs
NO
Well Baby Visits and Care

Covered under preventive care.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging

Cost share is driven by Provider setting.

YES

25.00% Coinsurance after deductible

100.00%

Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan Variant 96751NH0160065-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.832675776
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 Gold Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 40.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 1), Individual $0
Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 40.00%
Drug EHB Deductible, In Network (Tier 2), Family Per Group $0 per group
Drug EHB Deductible, In Network (Tier 2), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 2), Individual $0
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, Pregnancy
First Tier Utilization 51%
Formulary ID NHF002
Formulary URL URL
HIOS Product ID 96751NH016
HSA/HRA Employer Contribution No
Import Date 5/9/2023 20:01
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 Actuarial Value 81.63%
Issuer ID 96751
Issuer Marketplace Marketing Name Anthem Blue Cross and Blue Shield
Market Coverage SHOP (Small Group)
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 25.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $1500 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $500 per person
Medical EHB Deductible, In Network (Tier 1), Individual $500
Medical EHB Deductible, In Network (Tier 2), Default Coinsurance 25.00%
Medical EHB Deductible, In Network (Tier 2), Family Per Group $1500 per group
Medical EHB Deductible, In Network (Tier 2), Family Per Person $500 per person
Medical EHB Deductible, In Network (Tier 2), Individual $500
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Gold
Multiple In Network Tiers Yes
National Network No
Network ID NHN003
Out of Country Coverage No
Out of Country Coverage Description Emergency Coverage Only
Out of Service Area Coverage No
Out of Service Area Coverage Description TRAD/PAR network
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 96751NH0160065-00
Plan Marketing Name Anthem Gold Pathway X HMO 500/25%/7000
Plan Type HMO
Plan Variant Marketing Name Anthem Gold Pathway X HMO 500/25%/7000
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,700
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $2,100
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $300
SBC Scenario, Treatment of a Simple Fracture, Copayment $600
SBC Scenario, Treatment of a Simple Fracture, Deductible $500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 49%
Service Area ID NHS002
Source Name SERFF
Specialty Drug Maximum Coinsurance $650
Plan ID 96751NH0160065
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $7,000
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 Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan, 96751NH0160065

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

Frequently Asked Questions(FAQ) about Anthem Gold Pathway X HMO 500/25%/7000, 96751NH0160065 Health Insurance Plan, 96751NH0160065

  • Does Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan, 96751NH0160065 support Mail Ordering?

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

  • Does (96751NH0160065) Health Insurance Plan, Variant (96751NH0160065-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy

    Does (96751NH0160065) Health Insurance Plan, Variant (96751NH0160065-00) have Out Of Country Coverage?

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

    Does (96751NH0160065) Health Insurance Plan, Variant (96751NH0160065-00) 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 (96751NH0160065) Health Insurance Plan, Variant (96751NH0160065-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy

    Does Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan, Variant (96751NH0160065-00) offer Disease Management Programs for Asthma?

    Yes, the Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan Variant 96751NH0160065-00 offers Disease Management Program for Asthma.

    Does Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan, Variant (96751NH0160065-00) offer Disease Management Programs for Heart disease?

    Yes, the Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan Variant 96751NH0160065-00 offers Disease Management Program for Heart disease.

    Does Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan, Variant (96751NH0160065-00) offer Disease Management Programs for Depression?

    Yes, the Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan Variant 96751NH0160065-00 offers Disease Management Program for Depression.

    Does Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan, Variant (96751NH0160065-00) offer Disease Management Programs for Diabetes?

    Yes, the Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan Variant 96751NH0160065-00 offers Disease Management Program for Diabetes.

    Does Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan, Variant (96751NH0160065-00) offer Disease Management Programs for Pregnancy?

    Yes, the Anthem Gold Pathway X HMO 500/25%/7000 Health Insurance Plan Variant 96751NH0160065-00 offers Disease Management Program for Pregnancy.

 

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