New Hampshire health plan · 2025

NH Local HMO Gold 1500 Standard · 59025NH0370084

Harvard Pilgrim Healthcare, Inc. offers this marketplace health insurance plan (Plan ID 59025NH0370084) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Gold Plan type: HMO CSR: Standard Gold On Exchange Plan Issuer: Harvard Pilgrim Healthcare, Inc.
Telehealth Data pending HSA eligible No Dental Not listed Vision Adult/Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 78.06% (21.94% member share on average). Learn about AV methodology.

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$306 – $1200

Before subsidies

Estimate after subsidies

Deductible

$1,500

$3000 per group

See deductible details

Max out-of-pocket

$7,800

$15600 per group

Review MOOP rules

Office visits

Primary care $30.00
Specialist $60.00
HSA Not eligible

Drug tiers

Generic $15.00
Preferred brand $30.00

View formulary tiers

$419 / mo before subsidies

≈ $5030 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1328 / mo before subsidies

≈ $15938 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$1609 / mo before subsidies

≈ $19302 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$1022 / mo before subsidies

≈ $12267 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

0.00%

Emergency Room Services

25.00% Coinsurance after deductible

Durable Medical Equipment

25.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in New Hampshire). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Standard Gold On Exchange Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

0.00%

Emergency Room Services

25.00% Coinsurance after deductible

Durable Medical Equipment

25.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 59025NH0370084
Coverage year 2025
State New Hampshire
Issuer Harvard Pilgrim Healthcare, Inc.
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 59025NH0370084-01
Available variants

Standard Off Exchange Plan · 59025NH0370084-00

Standard On Exchange Plan · 59025NH0370084-01

Open to Indians below 300% FPL · 59025NH0370084-02

Open to Indians above 300% FPL · 59025NH0370084-03
Last plan update Thu, 03 Oct 2024 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in New Hampshire 1347
PCPs in New Hampshire 202
Telehealth support Data pending
Nationwide providers 6665
1,347 doctors statewide 202 PCPs 8 OB/GYN

Provider network(s)

Providers New Hampshire All US states
All 1347 6665
PCP 202 436
Allergy 1 1
OB/GYN 8 19
Dentists 3 3

Drug coverage overview

4,201 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
GENERIC 2,401
NON-PREFERRED-BRAND 593
NON-PREFERRED-GENERIC-PREFERRED-BRAND 562
NON-PREFERRED-BRAND-SPECIALTY-DRUGS 367
MEDICAL-SERVICE-DRUGS 278
Prior authorization Drugs
Required 817
Not Required 3,384
Step therapy Drugs
Required 43
Not Required 4,158
Quantity limits Drugs
Has Limit 600
No Limit 3,601

Customer highlights

What stands out for members

  • Issuer: Harvard Pilgrim Healthcare, Inc. · Plan ID 59025NH0370084 · 2025 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 59025NH0370084-01 (Standard On Exchange Plan) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

There is no visit limit for Chiropractic Care, however member cost sharing applies.

Exclusions: nan

Diabetes Care Management

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

nan

Exclusions: nan

Diabetes Education

$60.00
Tier 1 in-network $60.00
Out-of-network 100.00%

The Plan covers outpatient self-management education and training for the treatment of diabetes, including medical nutrition therapy services, used to diagnose or treat insulin-dependent diabetes, non-insulin dependent diabetes, or gestational diabetes. Services must be provided on an individual basis and be provided by a Plan Provider

Exclusions: nan

Home Health Care Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Laboratory Outpatient and Professional Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their lab services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information.

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

nan

Exclusions: nan

Preventive Care/Screening/Immunization

0.00%
Tier 1 in-network 0.00%
Out-of-network 100.00%

Certain preventive services as defined in Federal law are covered with no Out-Of-Pocket cost to member when provided by a Plan Provider.

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

You can access medical urgent care with $0 cost sharing from our virtual provider, Doctor on Demand. Visit doctorondemand.com/harvardpilgrim for more information.

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Exclusions: nan

Rehabilitative Speech Therapy

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Exclusions: nan

Specialist Visit

$60.00
Tier 1 in-network $60.00
Out-of-network 100.00%

You can access medical urgent care with $0 cost sharing from our virtual provider, Doctor on Demand. Visit doctorondemand.com/harvardpilgrim for more information.

Exclusions: nan

Urgent Care Centers or Facilities

$45.00
Tier 1 in-network $45.00
Out-of-network 100.00%

Urgent care centers can be both freestanding and hospital-based. Receiving care from freestanding urgent care clinics often has lower member out of pocket cost. To locate freestanding urgent care clinics in our network, search for 'Urgent Care Center' provider type in the online provider directory.

Exclusions: nan

X-rays and Diagnostic Imaging

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their imaging services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information.

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Bone Marrow Transplant

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital- Acute Inpatient setting.

Exclusions: nan

Chemotherapy

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital-Outpatient setting.

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

48 Hour Minimum Stay-Vaginal; 96 Hour Minimum Stay-Cesarean.

Exclusions: nan

Dialysis

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Plan approval required for dialysis services when temporarily traveling outside of the state where you live. Such coverage is only provided for up to 30 days per calendar year.

Exclusions: nan

Durable Medical Equipment

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

One breast pump per birth (rented or purchased)

Exclusions: nan

Emergency Room Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 25.00% Coinsurance after deductible

Emergency room copayments are waived when a member is directly admitted to the hospital.

Exclusions: nan

Emergency Transportation/Ambulance

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 25.00% Coinsurance after deductible

If you have a Medical Emergency, your Plan covers ambulance transport to the nearest Hospital that can provide care.

Exclusions: nan

Hospice Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospice-Outpatient setting.

Exclusions: nan

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

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Inpatient Physician and Surgical Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Inpatient Rehabilitation Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 100.0 Days per Year

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Coverage is provided for inpatient mental health, substance use disorder and detoxification services.

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

Coverage is provided for care provided in-person, virtually, through secure digital messaging and through e-visits.

Exclusions: nan

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

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Outpatient Rehabilitation Services

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Radiation

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital-Outpatient setting.

Exclusions: nan

Skilled Nursing Facility

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 100.0 Days per Year

Coverage limited to 100 days per year. Custodial or Long Term Care is not covered.

Exclusions: nan

Substance Abuse Disorder Inpatient Services

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Coverage is provided for inpatient mental health, substance use disorder and detoxification services.

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

Coverage is provided for care provided in-person, virtually, through secure digital messaging and through e-visits.

Exclusions: nan

Transplant

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital- Acute Inpatient setting.

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

Coverage is not provided for pediatric dental care.

Exclusions: nan

Hearing Aids

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

Coverage is limited to 1 hearing aid per hearing-impaired ear when medically necessary.

Exclusions: nan

Major Dental Care - Child

Coverage details pending

Coverage is not provided for pediatric dental care.

Exclusions: nan

Prenatal and Postnatal Care

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 100.00%

Routine Prenatal and Postnatal Care are covered in full.

Exclusions: nan

Routine Eye Exam for Children

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Year

Members under the age of 19 are covered for one routine eye exam every year.

Exclusions: nan

Well Baby Visits and Care

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 100.00%

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$15.00
Tier 1 in-network $15.00
Out-of-network 100.00%

Certain preventative services are covered at no cost to the member. See a complete list at harvardpilgrim.org Coverage for some generic OTC medications is available at tier 1 Rx cost sharing. You can use the drug lookup tool at harvardpilgrim.com/rx to search the formulary for OTC medications you may be taking. Members save money by obtaining a 90-day supply of tier 1 maintenance medications through our mail order pharmacy.

Exclusions: nan

Non-Preferred Brand Drugs

$60.00
Tier 1 in-network $60.00
Out-of-network 100.00%

Members may have a lower total out of pocket cost when they obtain a 90-day supply of maintenance medications through our mail order pharmacy.

Exclusions: nan

Off Label Prescription Drugs

$250.00
Tier 1 in-network $250.00
Out-of-network 100.00%

nan

Exclusions: nan

Preferred Brand Drugs

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

Members save money by obtaining a 90-day supply of tier 2 maintenance medications through our mail order pharmacy.

Exclusions: nan

Specialty Drugs

$250.00
Tier 1 in-network $250.00
Out-of-network 100.00%

Members may have a lower total out of pocket cost when they obtain a 90-day supply of maintenance medications through our mail order pharmacy.

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

Coverage for treatment resulting from accidental injury to sound natural teeth and gums. Repairs to teeth with damage resulting from normal activities of daily living or extraordinary use of the teeth is not covered.

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

Coverage is not provided for adult dental care.

Exclusions: nan

Dental Anesthesia

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital- Acute Inpatient setting.

Exclusions: nan

Dental Check-Up for Children

Coverage details pending

Coverage is not provided for pediatric dental care.

Exclusions: nan

Infusion Therapy

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital-Outpatient setting.

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

Coverage is not provided for adult dental care.

Exclusions: nan

Nutritional Counseling

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

Coverage is not provided for adult dental care.

Exclusions: nan

Orthodontia - Child

Coverage details pending

Coverage is not provided for pediatric dental care.

Exclusions: nan

Prosthetic Devices

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Coveage is provided for (a) the least costly prosthetic device adequate to allow you to perform Activities of Daily Living. Activities of Daily Living do not include special functions needed for occupational purposes or sports; and (b) one item of each type of prosthetic device. No back-up items or items that serve a duplicate purpose are covered.

Exclusions: nan

Routine Dental Services (Adult)

Coverage details pending

nan

Exclusions: nan

Weight Loss Programs

Coverage details pending

There is no coverage for weight loss programs. Members can get reimbursement for a fitness club membership or virtual fitness class subscription. Learn more by visiting harvardpilgrim.org/fitnessreimbursement. Through our partner, WebMD, program members can earn rewards for participating in a variety of informative and interactive activities that supports all aspects of well-being, including healthy eating, physical activity, financial wellness, mindfulness and meditation, self-care and stress management This program is a subscriber-only program and participants can earn up to $120 in rewards per year.

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

Coverage is not provided for abortion, except when the life of the mother is endangered or when the pregnancy is a result of rape or incest.

Exclusions: nan

Acupuncture

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

There is no visit limit for Acupuncture, however member cost sharing applies.

Exclusions: nan

Allergy Testing

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Applied Behavior Analysis Based Therapies

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

nan

Exclusions: nan

Bariatric Surgery

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

In order to receive coverage for bariatric surgery, care must be received from a designated center of excellence. To verify a provider's status, refer to the online provider directory.

Exclusions: nan

Convenience Care Clinic

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

nan

Exclusions: nan

Cosmetic Surgery

Coverage details pending

nan

Exclusions: nan

Early Intervention Services

No Charge, No Charge
Tier 1 in-network No Charge, No Charge
Out-of-network 100.00%

Limit: 40.0 Visit(s) per Year

For Members under the age of 3, coverage is available for services rendered by occupational therapists, physical therapists, speech-language pathologists and clinical social workers

Exclusions: nan

Eye Glasses for Children

50.00%
Tier 1 in-network 50.00%
Out-of-network 50.00%

Limit: 1.0 Item(s) per Year

Each dependent under the age of 19 is covered every 12 months for either (a) 1 pair of standard or basic eyeglass frames and lenses or (b) contact lenses. Limits apply, refer to the Schedule of Benefits.

Exclusions: nan

Gender Affirming Care

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital- Acute Inpatient setting.

Exclusions: nan

Habilitation Services

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Physical, Occupational, and Speech Therapy have a combined visit limit of 60 visits per year. Visits for (a) children up to the age of 3 or (b) for the treatment of autism do not count toward the limit.

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Members can earn cash rewards and may lower their out-of-pocket cost by obtaining their imaging services at high-quality, cost-effective providers. Visit harvardpilgrim.org/reducecosts for more information.

Exclusions: nan

Infertility Treatment

Coverage details pending

Covered benefits include consultation, evaluation and laboratory testing. Coverage is also provided for services to treat underlying medical conditions that may cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). Infertility drugs and treatment such as therapeutic donor insemination and advanced reproductive technologies are excluded from coverage.

Exclusions: nan

Inherited Metabolic Disorders - PKU

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Low Protein Foods

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Private-Duty Nursing

Coverage details pending

nan

Exclusions: nan

Reconstructive Surgery

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Hospital- Acute Inpatient setting.

Exclusions: nan

Routine Eye Exam (Adult)

$30.00
Tier 1 in-network $30.00
Out-of-network 100.00%

Limit: 1.0 Exam(s) per 2 Years

Adults are covered for one routine eye exam every 2 years.

Exclusions: nan

Routine Foot Care

$60.00
Tier 1 in-network $60.00
Out-of-network 100.00%

Excluded, except for preventive foot care for members with diabetes or systemic circulatory diseases.

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

Provided in a Surgery-Outpatient setting.

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.

Wigs

25.00% Coinsurance after deductible
Tier 1 in-network 25.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Variant attributes

NH Local HMO Gold 1500 Standard · Variant 59025NH0370084-01

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Standard Gold On Exchange Plan

HIOS Product ID

59025NH037

Metal Level

Gold

Plan ID (Standard Component ID with Variant)

59025NH0370084-01

Plan Marketing Name

NH Local HMO Gold 1500 Standard

Plan Variant Marketing Name

NH Local HMO Gold 1500 Standard

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

59025

Issuer Marketplace Marketing Name

Harvard Pilgrim Health Care

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

No

Network ID

NHN002

Out of Country Coverage

No

Out of Service Area Coverage

No

Service Area ID

NHS001

State Code

NH

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.780612576352931

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

Yes

Medical Drug Maximum Out of Pocket Integrated

Yes

SBC Scenario, Having a Baby, Coinsurance

$2,800

SBC Scenario, Having a Baby, Copayment

$70

SBC Scenario, Having a Baby, Deductible

$1,500

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$1,500

SBC Scenario, Having Diabetes, Deductible

$100

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$200

SBC Scenario, Treatment of a Simple Fracture, Copayment

$200

SBC Scenario, Treatment of a Simple Fracture, Deductible

$1,500

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, In Network (Tier 1), Default Coinsurance

25.00%

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$15600 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$7800 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$7,800

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

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

NHF016

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$0

SBC Scenario, Having Diabetes, Limit

$0

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Dental Only Plan

No

Design Type

Design 1

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

EHB Percent of Total Premium

0.997181

First Tier Utilization

100%

Import Date

2024-10-03 20:01:44

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

New

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

Yes

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

HMO

QHP/Non QHP

Both

Source Name

SERFF

Specialist Requiring a Referral

A Referral is Needed for all Specialist except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.

Plan ID

59025NH0370084

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), Family Per Group

$3000 per group

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person

$1500 per person

Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual

$1,500

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

Unique Plan Design

No

Wellness Program Offered

Yes

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in New Hampshire?

NH Local HMO Gold 1500 Standard (59025NH0370084) is a Gold HMO from Harvard Pilgrim Healthcare, Inc. in New Hampshire for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does NH Local HMO Gold 1500 Standard support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is NH Local HMO Gold 1500 Standard HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental coverage is not listed for this plan.

Vision add-ons: Adult, Child.

Does NH Local HMO Gold 1500 Standard support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with NH Local HMO Gold 1500 Standard?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.

Is there out-of-country coverage for NH Local HMO Gold 1500 Standard?

No, out-of-country services are not covered for this plan.

Does NH Local HMO Gold 1500 Standard cover care outside the service area?

No, the issuer indicates out-of-service-area care is not covered except for emergencies.

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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