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 100.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% 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 100.00% (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 0.00% 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 | 59025NH0370059-02 | ||||||||||||||||||
| 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 - 59025NH0370059-00 Standard On Exchange Plan - 59025NH0370059-01 |
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| Last Plan Update Date | Thu, 18 Aug 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of NH Local Choice HMO Bronze 7200 Health Insurance Plan, 59025NH0370059-02
| 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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Acupuncture
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Allergy Testing
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Bariatric Surgery
Provided in a Hospital- Acute Inpatient setting. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Chemotherapy
Provided in a Hospital-Outpatient setting. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Chiropractic Care
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Convenience Care Clinic
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Dental Anesthesia
Provided in a Hospital- Acute Inpatient setting. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Diabetes Education
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Dialysis
Provided in a Hospital-Outpatient setting. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Early Intervention Services
Limit: 40.0 Visit(s) per Year For Members under the age of 3 |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Emergency Room Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
| 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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
$0.00, 0.00% |
| Gender Affirming Care
Provided in a Hospital- Acute Inpatient setting. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Generic Drugs
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Hearing Aids
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Home Health Care Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Hospice Services
Provided in a Hospice-Outpatient setting. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Provided in a Hospital-Outpatient setting. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Inherited Metabolic Disorders - PKU
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Inpatient Rehabilitation Services
Limit: 100.0 Days per Year |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Low Protein Foods
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Non-Preferred Brand Drugs
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Off Label Prescription Drugs
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Preferred Brand Drugs
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
Routine Prenatal and Postnatal Care are covered in full. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Radiation
Provided in a Hospital-Outpatient setting. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Reconstructive Surgery
Provided in a Hospital- Acute Inpatient setting. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year For Members under the age of 19 |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Routine Foot Care
Exclusions: Excluded for all diagnosis, except for the treatment of diabetes. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Skilled Nursing Facility
Limit: 100.0 Days per Year |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Specialist Visit
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Specialty Drugs
Exclusions: Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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 | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Transplant
Provided in a Hospital- Acute Inpatient setting. |
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
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: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| Wigs
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | Tier 1: $0.00, 0.00% Tier 2: $0.00, 0.00% |
100.00% |
NH Local Choice HMO Health Insurance Plan Variant 59025NH0370059-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1 |
| 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 | Zero Cost Sharing Plan Variation |
| 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 | 100.00% |
| 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) | 59025NH0370059-02 |
| Plan Marketing Name | NH Local Choice HMO Bronze 7200 |
| Plan Type | HMO |
| Plan Variant Marketing Name | NH Local Choice HMO |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| 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 | $0 |
| 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 | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| 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 (59025NH0370059-02) offer Disease Management Programs?
Does (59025NH0370059) Health Insurance Plan, Variant (59025NH0370059-02) have Out Of Country Coverage?
Does (59025NH0370059) Health Insurance Plan, Variant (59025NH0370059-02) have Out of Service Area Coverage?
Does (59025NH0370059) Health Insurance Plan, Variant (59025NH0370059-02) offer Disease Management Programs?
Does NH Local Choice HMO Health Insurance Plan, Variant (59025NH0370059-02) offer Disease Management Programs for Asthma?
Does NH Local Choice HMO Health Insurance Plan, Variant (59025NH0370059-02) offer Disease Management Programs for Heart disease?
Does NH Local Choice HMO Health Insurance Plan, Variant (59025NH0370059-02) offer Disease Management Programs for Depression?
Does NH Local Choice HMO Health Insurance Plan, Variant (59025NH0370059-02) offer Disease Management Programs for Diabetes?
Does NH Local Choice HMO Health Insurance Plan, Variant (59025NH0370059-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does NH Local Choice HMO Health Insurance Plan, Variant (59025NH0370059-02) offer Disease Management Programs for Low back pain?
Does NH Local Choice HMO Health Insurance Plan, Variant (59025NH0370059-02) offer Disease Management Programs for Pregnancy?
Does NH Local Choice HMO Health Insurance Plan, Variant (59025NH0370059-02) offer Disease Management Programs for Weight loss programs?
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