Focused Silver + Vision + Adult Dental - 75841NH0100028 Health Insurance Plan
Celtic Insurance Company health insurance plan with the Plan ID 75841NH0100028. The plan is called Focused Silver + Vision + Adult Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.15% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.85% 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 70.21% (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 29.79% 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 | 75841NH0100028 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| 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 | 75841NH0100028-00 | ||||||||||||||||||
| Provider Network(s) | ['NHN001'] | ||||||||||||||||||
| 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 - 75841NH0100028-00 Standard On Exchange Plan - 75841NH0100028-01 Open to Indians below 300% FPL - 75841NH0100028-02 Open to Indians above 300% FPL - 75841NH0100028-03 73% AV Silver Plan - 75841NH0100028-04 |
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| Last Plan Update Date | Fri, 18 Nov 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Focused Silver + Vision + Adult Dental Health Insurance Plan, 75841NH0100028-00
| 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 or authorized within 3 months of the date of the injury. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $100.00 |
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 | 50.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
100.00% |
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Year |
YES | $90.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $100.00 |
100.00% |
| Dialysis
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
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 |
| Eyeglasses for Adults
Limit: 1.0 Item(s) per Year Excluded from In-Network MOOP |
YES | No Charge |
100.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan's Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost. |
YES | $22.60 |
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 No Limit. 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 'Maintece Therapy,' defined as 'Treatment given when no further gains are clear or likely to occur. Maintece 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 | 50.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per 3 Years One hearing aid per ear each time a hearing aid prescription changes. Cochlear & Bone Anchored Hearing Aids are a covered benefit. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Cost share is based on place of service. |
YES | 50.00% 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 | 50.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Cost share is based on place of service. |
YES | $50.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Emergency Room
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health ER Physician Fee
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Other Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $45.00 |
100.00% |
| Mental/Behavioral Health Urgent Care
|
YES | $60.00 |
$60.00 |
| Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | $100.00 |
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% Coinsurance after deductible |
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 No Limit. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $75.00 |
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 Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs. |
YES | $45.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 50.00% Coinsurance after deductible |
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 No Limit. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
Limit: 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Year Excluded from In Network MOOP |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
This Plan covers a complete eye exam with dilation, as needed. |
YES | No Charge |
100.00% |
| Routine Foot Care
Prior authorization may be required. Covered no limit. |
YES | $100.00 |
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 | 50.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $100.00 |
100.00% |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $45.00 |
100.00% |
| Substance Use Disorder Emergency Room
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Use Disorder ER Physician Fee
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Use Disorder Outpatient Other Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Use Disorder Urgent Care
|
YES | $60.00 |
$60.00 |
| Transplant
Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
YES | 50.00% 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% Coinsurance after deductible |
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
Cost share is based on place of service. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Focused Silver + Vision + Adult Dental Health Insurance Plan Variant 75841NH0100028-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.702111134 |
| 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 Silver Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 0.9461 |
| First Tier Utilization | 100% |
| Formulary ID | NHF006 |
| Formulary URL | URL |
| HIOS Product ID | 75841NH010 |
| Import Date | 11/18/2022 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 70.15% |
| Issuer ID | 75841 |
| Issuer Marketplace Marketing Name | Ambetter from NH Healthy Families |
| 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 Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 75841NH0100028-00 |
| Plan Marketing Name | Focused Silver + Vision + Adult Dental |
| Plan Type | EPO |
| Plan Variant Marketing Name | Focused Silver + Vision + Adult Dental |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $800 |
| SBC Scenario, Having a Baby, Copayment | $600 |
| SBC Scenario, Having a Baby, Deductible | $6,100 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,800 |
| SBC Scenario, Having Diabetes, Deductible | $800 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| 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 | 75841NH0100028 |
| 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 | $12200 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6100 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,100 |
| 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 | $15000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,500 |
| 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 Focused Silver + Vision + Adult Dental Health Insurance Plan, 75841NH0100028
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Focused Silver + Vision + Adult Dental, 75841NH0100028 Health Insurance Plan, 75841NH0100028
-
Does Focused Silver + Vision + Adult Dental Health Insurance Plan, 75841NH0100028 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (75841NH0100028) Health Insurance Plan, Variant (75841NH0100028-00) offer Disease Management Programs?
Does (75841NH0100028) Health Insurance Plan, Variant (75841NH0100028-00) have Out Of Country Coverage?
Does (75841NH0100028) Health Insurance Plan, Variant (75841NH0100028-00) have Out of Service Area Coverage?
Does (75841NH0100028) Health Insurance Plan, Variant (75841NH0100028-00) offer Disease Management Programs?
Does Focused Silver + Vision + Adult Dental Health Insurance Plan, Variant (75841NH0100028-00) offer Disease Management Programs for Asthma?
Does Focused Silver + Vision + Adult Dental Health Insurance Plan, Variant (75841NH0100028-00) offer Disease Management Programs for Heart disease?
Does Focused Silver + Vision + Adult Dental Health Insurance Plan, Variant (75841NH0100028-00) offer Disease Management Programs for Diabetes?
Does Focused Silver + Vision + Adult Dental Health Insurance Plan, Variant (75841NH0100028-00) 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