Elite Bronze - 75841NH0090021 Health Insurance Plan
Celtic Insurance Company health insurance plan with the Plan ID 75841NH0090021. The plan is called Elite Bronze.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.88% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.12% 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 71.82% (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 28.18% 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 | 75841NH0090021 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | New Hampshire | ||||||||||||||||||
| Health Insurance Issuer | Celtic Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 75841NH0090021-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 75841NH0090021-00 Standard On Exchange Plan - 75841NH0090021-01 |
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| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Elite Bronze Health Insurance Plan, 75841NH0090021-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
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. |
YES | 50.00% |
100.00% |
| Acupuncture
|
YES | $45.00 |
100.00% |
| Allergy Testing
|
YES | $115.00 |
100.00% |
| Bariatric Surgery
|
YES | $3,000.00 |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year |
YES | $80.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $3,000.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $115.00 |
100.00% |
| Dialysis
|
YES | 50.00% |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% |
100.00% |
| Emergency Room Services
|
YES | $2,500.00 |
$2,500.00 |
| Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | 50.00% |
50.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | $3,000.00 |
100.00% |
| Generic Drugs
Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. |
YES | $3.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy). Cardiac rehab & pulmonary rehab have no limit. Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | 50.00% |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per Procedure One hearing aid per ear each time a hearing aid prescription changes. Cochlear & Bone Anchored Hearing Aids are a covered benefit. |
YES | 50.00% |
100.00% |
| Home Health Care Services
|
YES | 50.00% |
100.00% |
| Hospice Services
Respite Care is a covered as part of hospice services only. |
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% |
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 | 50.00% |
100.00% |
| Infusion Therapy
|
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $3,000.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $60.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit. |
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Emergency Room
|
YES | $1,250.00 |
$1,250.00 |
| Mental/Behavioral Health Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | $1,250.00 |
$1,250.00 |
| Mental/Behavioral Health ER Physician Fee
|
YES | $1,250.00 |
$1,250.00 |
| Mental/Behavioral Health Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $3,000.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
|
YES | 50.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | $45.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $45.00 |
$45.00 |
| Non-Preferred Brand Drugs
|
YES | $250.00 Copay after deductible |
100.00% |
| Nutritional Counseling
|
YES | $115.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $45.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy). Cardiac rehab & pulmonary rehab have no limit. Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | 50.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% |
100.00% |
| Preferred Brand Drugs
|
YES | $195.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $45.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Unlimited Virtual 24/7 Care Visits received from Ambetter?s designated telehealth provider covered at No Charge, except for HSAs. |
YES | $45.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
|
YES | 50.00% |
100.00% |
| Reconstructive Surgery
1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality... 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card. |
YES | $3,000.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy). Cardiac rehab & pulmonary rehab have no limit. Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | 50.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy). Cardiac rehab & pulmonary rehab have no limit. Limits do not apply when provided for a mental health/substance use disorder diagnosis. |
YES | 50.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year This Plan covers a complete eye exam with dilation, as needed. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
YES | $115.00 |
100.00% |
| Skilled Nursing Facility
Limit: 100.0 Days per Year |
YES | $3,000.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $115.00 |
100.00% |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Prior authorization may be required - please contact the number listed on your ID card. |
YES | $3,000.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. |
YES | $45.00 |
100.00% |
| Substance Use Disorder Emergency Room
|
YES | $1,250.00 |
$1,250.00 |
| Substance Use Disorder Emergency Transportation/Ambulance
Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing. |
YES | $1,250.00 |
$1,250.00 |
| Substance Use Disorder ER Physician Fee
|
YES | $1,250.00 |
$1,250.00 |
| Substance Use Disorder Outpatient Other Services
|
YES | 50.00% |
100.00% |
| Substance Use Disorder Urgent Care
|
YES | $45.00 |
$45.00 |
| Tier 3 Generic Drugs
Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information. |
YES | $35.00 |
100.00% |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | $3,000.00 |
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 | $60.00 |
$60.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Covered under preventive care. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 50.00% |
100.00% |
Elite Bronze Health Insurance Plan Variant 75841NH0090021-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7181614327435408 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze 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 | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7600 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3800 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $3,800 |
| 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 |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | NHF002 |
| Formulary URL | URL |
| HIOS Product ID | 75841NH009 |
| Import Date | 2023-08-16 20:01:48 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 64.88% |
| Issuer ID | 75841 |
| Issuer Marketplace Marketing Name | Ambetter from NH Healthy Families |
| Market Coverage | Individual |
| 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 | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NHN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 75841NH0090021-00 |
| Plan Marketing Name | Elite Bronze |
| Plan Type | EPO |
| Plan Variant Marketing Name | Elite Bronze |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $200 |
| SBC Scenario, Having a Baby, Copayment | $3,600 |
| SBC Scenario, Having a Baby, Deductible | $10 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $400 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $3,500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $10 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NHS001 |
| Source Name | SERFF |
| Plan ID | 75841NH0090021 |
| 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 | $18500 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9250 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,250 |
| 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 Elite Bronze Health Insurance Plan, 75841NH0090021
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Elite Bronze, 75841NH0090021 Health Insurance Plan, 75841NH0090021
-
Does Elite Bronze Health Insurance Plan, 75841NH0090021 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (75841NH0090021) Health Insurance Plan, Variant (75841NH0090021-00) offer Disease Management Programs?
Does (75841NH0090021) Health Insurance Plan, Variant (75841NH0090021-00) have Out Of Country Coverage?
Does (75841NH0090021) Health Insurance Plan, Variant (75841NH0090021-00) have Out of Service Area Coverage?
Does (75841NH0090021) Health Insurance Plan, Variant (75841NH0090021-00) offer Disease Management Programs?
Does Elite Bronze Health Insurance Plan, Variant (75841NH0090021-00) offer Disease Management Programs for Asthma?
Does Elite Bronze Health Insurance Plan, Variant (75841NH0090021-00) offer Disease Management Programs for Heart disease?
Does Elite Bronze Health Insurance Plan, Variant (75841NH0090021-00) offer Disease Management Programs for Diabetes?
Does Elite Bronze Health Insurance Plan, Variant (75841NH0090021-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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