NH Local Choice HMO Bronze 7200 - 59025NH0370059 Health Insurance Plan

Harvard Pilgrim Health Care of NE health insurance plan with the Plan ID 59025NH0370059. The plan is called NH Local Choice HMO Bronze 7200.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.15% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.85% 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 64.83% (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 35.17% 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 59025NH0370059
Health Insurance Plan Year 2023
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 59025NH0370059-00
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 - 59025NH0370059-00

Standard On Exchange Plan - 59025NH0370059-01

Open to Indians below 300% FPL - 59025NH0370059-02

Open to Indians above 300% FPL - 59025NH0370059-03

Last Plan Update Date Thu, 18 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of NH Local Choice HMO Bronze 7200 Health Insurance Plan, 59025NH0370059-00

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.

Copay applies to the first 3 visits with a Primary Care Physician. Deductible then coinsurance apply after the first 3 visits with a Primary Care Physician per member

YES

50.00% Coinsurance after deductible

100.00%
Acupuncture
YES

50.00% Coinsurance after deductible

100.00%
Allergy Testing
YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Applied Behavior Analysis Based Therapies

No cost sharing applies to the first 3 Mental Health outpatient office visits per member. Deductible then coinsurance apply after the first 3 Mental Health outpatient office visits per member

YES

50.00% Coinsurance after deductible

100.00%
Bariatric Surgery

Provided in a Hospital- Acute Inpatient setting.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge 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: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Chemotherapy

Provided in a Hospital-Outpatient setting.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Chiropractic Care
YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Convenience Care Clinic
YES

50.00% Coinsurance after deductible

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

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Dental Anesthesia

Provided in a Hospital- Acute Inpatient setting.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Care Management

Copay applies to the first 3 visits with a Primary Care Physician. Deductible then coinsurance apply after the first 3 visits with a Primary Care Physician per member

YES

Tier 1: $40.00, 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Diabetes Education
YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Dialysis

Provided in a Hospital-Outpatient setting.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Durable Medical Equipment
YES

50.00% 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

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

50.00% Coinsurance after deductible

50.00% 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: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Generic Drugs
YES

$10.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Year

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Hearing Aids
YES

50.00%

100.00%
Home Health Care Services
YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Hospice Services

Provided in a Hospice-Outpatient setting.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

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

Tier 1: No Charge after deductible, 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Provided in a Hospital-Outpatient setting.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Inherited Metabolic Disorders - PKU
YES

50.00% Coinsurance after deductible

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

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Inpatient Rehabilitation Services

Limit: 100.0 Days per Year

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Low Protein Foods
YES

50.00% Coinsurance after deductible

100.00%
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

No cost sharing applies to the first 3 Mental Health outpatient office visits per member. Deductible then coinsurance apply after the first 3 Mental Health outpatient office visits per member

YES

50.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs
YES

40.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Copay applies to the first 3 visits with a Primary Care Physician. Deductible then coinsurance apply after the first 3 visits with a Primary Care Physician per member

YES

Tier 1: $40.00, 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Off Label Prescription Drugs
YES

40.00% Coinsurance after deductible

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

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

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

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge 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: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Preferred Brand Drugs
YES

35.00% Coinsurance after deductible

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

Copay applies to the first 3 visits with a Primary Care Physician. Deductible then coinsurance apply after the first 3 visits with a Primary Care Physician per member

YES

Tier 1: $40.00, 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

50.00% Coinsurance after deductible

100.00%
Radiation

Provided in a Hospital-Outpatient setting.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Reconstructive Surgery

Provided in a Hospital- Acute Inpatient setting.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge 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: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge 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: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge 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: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge 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: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Routine Foot Care

Exclusions: Excluded for all diagnosis, except for the treatment of diabetes.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Skilled Nursing Facility

Limit: 100.0 Days per Year

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Specialist Visit
YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge 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

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

No cost sharing applies to the first 3 Mental Health outpatient office visits per member. Deductible then coinsurance apply after the first 3 Mental Health outpatient office visits per member

YES

50.00% Coinsurance after deductible

100.00%
Transplant

Provided in a Hospital- Acute Inpatient setting.

YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge 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: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%
Urgent Care Centers or Facilities
YES

50.00% Coinsurance after deductible

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
Wigs
YES

50.00% Coinsurance after deductible

100.00%
X-rays and Diagnostic Imaging
YES

Tier 1: 50.00% Coinsurance after deductible

Tier 2: No Charge after deductible, No Charge after deductible

100.00%

NH Local Choice HMO Bronze 7200 Health Insurance Plan Variant 59025NH0370059-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.648294236
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 3
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, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 0.997212
First Tier Utilization 70%
Formulary ID NHF001
Formulary URL URL
HIOS Product ID 59025NH037
Import Date 8/18/2022 20:01
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 64.15%
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 Expanded Bronze
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 1/1/2023
Plan Expiration Date 12/31/2050
Plan ID (Standard Component ID with Variant) 59025NH0370059-00
Plan Marketing Name NH Local Choice HMO Bronze 7200
Plan Type HMO
Plan Variant Marketing Name NH Local Choice HMO Bronze 7200
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,500
SBC Scenario, Having a Baby, Copayment $40
SBC Scenario, Having a Baby, Deductible $7,200
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $700
SBC Scenario, Having Diabetes, Deductible $1,900
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $10
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
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 59025NH0370059
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 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $14400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7200 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,200
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $17400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $8700 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $8,700
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $8,700
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 Bronze 7200 Health Insurance Plan, 59025NH0370059

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

Frequently Asked Questions(FAQ) about NH Local Choice HMO Bronze 7200, 59025NH0370059 Health Insurance Plan, 59025NH0370059

  • Does NH Local Choice HMO Bronze 7200 Health Insurance Plan, 59025NH0370059 support Mail Ordering?

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

  • Does (59025NH0370059) Health Insurance Plan, Variant (59025NH0370059-00) 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, Pregnancy, Weight Loss Programs

    Does (59025NH0370059) Health Insurance Plan, Variant (59025NH0370059-00) have Out Of Country Coverage?

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

    Does (59025NH0370059) Health Insurance Plan, Variant (59025NH0370059-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan).

    Does (59025NH0370059) Health Insurance Plan, Variant (59025NH0370059-00) 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, Pregnancy, Weight Loss Programs

    Does NH Local Choice HMO Bronze 7200 Health Insurance Plan, Variant (59025NH0370059-00) offer Disease Management Programs for Asthma?

    Yes, the NH Local Choice HMO Bronze 7200 Health Insurance Plan Variant 59025NH0370059-00 offers Disease Management Program for Asthma.

    Does NH Local Choice HMO Bronze 7200 Health Insurance Plan, Variant (59025NH0370059-00) offer Disease Management Programs for Heart disease?

    Yes, the NH Local Choice HMO Bronze 7200 Health Insurance Plan Variant 59025NH0370059-00 offers Disease Management Program for Heart disease.

    Does NH Local Choice HMO Bronze 7200 Health Insurance Plan, Variant (59025NH0370059-00) offer Disease Management Programs for Depression?

    Yes, the NH Local Choice HMO Bronze 7200 Health Insurance Plan Variant 59025NH0370059-00 offers Disease Management Program for Depression.

    Does NH Local Choice HMO Bronze 7200 Health Insurance Plan, Variant (59025NH0370059-00) offer Disease Management Programs for Diabetes?

    Yes, the NH Local Choice HMO Bronze 7200 Health Insurance Plan Variant 59025NH0370059-00 offers Disease Management Program for Diabetes.

    Does NH Local Choice HMO Bronze 7200 Health Insurance Plan, Variant (59025NH0370059-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the NH Local Choice HMO Bronze 7200 Health Insurance Plan Variant 59025NH0370059-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does NH Local Choice HMO Bronze 7200 Health Insurance Plan, Variant (59025NH0370059-00) offer Disease Management Programs for Low back pain?

    Yes, the NH Local Choice HMO Bronze 7200 Health Insurance Plan Variant 59025NH0370059-00 offers Disease Management Program for Low back pain.

    Does NH Local Choice HMO Bronze 7200 Health Insurance Plan, Variant (59025NH0370059-00) offer Disease Management Programs for Pregnancy?

    Yes, the NH Local Choice HMO Bronze 7200 Health Insurance Plan Variant 59025NH0370059-00 offers Disease Management Program for Pregnancy.

    Does NH Local Choice HMO Bronze 7200 Health Insurance Plan, Variant (59025NH0370059-00) offer Disease Management Programs for Weight loss programs?

    Yes, the NH Local Choice HMO Bronze 7200 Health Insurance Plan Variant 59025NH0370059-00 offers Disease Management Program for Weight loss programs.

 

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