NH Local Choice HMO Bronze 8000

59025NH0370078
Expanded Bronze
HMO

NH Local Choice HMO Bronze 8000 is an Expanded Bronze HMO plan by Harvard Pilgrim Health Care.

IMPORTANT: You are viewing the 2024 version of NH Local Choice HMO Bronze 8000 59025NH0370078. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

NH Local Choice HMO Bronze 8000 is offered in the following counties.

No data was found

Plan Overview

This is a plan overview for 2024 version of NH Local Choice HMO Bronze 8000 59025NH0370078.
Insurer: Harvard Pilgrim Health Care
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 59025NH0370078

Cost-Sharing Overview

NH Local Choice HMO Bronze 8000 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for NH Local Choice HMO Bronze 8000?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

NH Local Choice HMO Bronze 8000 offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: A referral is needed for all specialists except for OB/GYN, Chiropractic Care, Routine Eye Exams, and Mental Health Providers.
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what NH Local Choice HMO Bronze 8000 covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

NH Local Choice HMO Bronze 8000 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% No cost sharing applies to the first 2 visits with a Primary Care Physician. Deductible then coinsurance apply after the first 2 visits with a Primary Care Physician per member
Specialist Visit
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Hospice Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Provided in a Hospice-Outpatient setting.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%1.0 Exam(s) per 2 Years For Members age 19 and over
Urgent Care Centers or Facilities
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Home Health Care Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Emergency Room Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable No Charge after deductible
Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductibleNot Applicable No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Bariatric Surgery
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Provided in a Hospital- Acute Inpatient setting.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%100.0 Days per Year
Prenatal and Postnatal Care
Covered
No Charge No ChargeNot Applicable 100.00% Routine Prenatal and Postnatal Care are covered in full.
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% No cost sharing applies to the first 2 Mental Health outpatient office visits per member. Deductible then coinsurance apply after the first 2 Mental Health outpatient office visits per member
Mental/Behavioral Health Inpatient Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% No cost sharing applies to the first 2 Mental Health outpatient office visits per member. Deductible then coinsurance apply after the first 2 Mental Health outpatient office visits per member
Substance Abuse Disorder Inpatient Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$10.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Preferred Brand Drugs
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered.
Outpatient Rehabilitation Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%60.0 Visit(s) per Year 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.
Habilitation Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%60.0 Visit(s) per Year 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.
Chiropractic Care
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Durable Medical Equipment
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Covered
Not Applicable 50.00%Not Applicable 100.00%
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge No ChargeNot Applicable 100.00%
Routine Foot Care
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Excluded for all diagnosis, except for the treatment of diabetes.
Acupuncture
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%1.0 Exam(s) per Year For Members under the age of 19
Eye Glasses for Children
Covered
Not Applicable 50.00%Not Applicable 50.00%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.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%60.0 Visit(s) per Year 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.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%60.0 Visit(s) per Year 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.
Well Baby Visits and Care
Covered
No Charge No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Provided in a Hospital- Acute Inpatient setting.
Accidental Dental
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% 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. No cost sharing applies to the first 2 visits with a Primary Care Physician. Deductible then coinsurance apply after the first 2 visits with a Primary Care Physician per member
Dialysis
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Provided in a Hospital-Outpatient setting.
Allergy Testing
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Chemotherapy
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Provided in a Hospital-Outpatient setting.
Radiation
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Provided in a Hospital-Outpatient setting.
Diabetes Education
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Provided in a Hospital-Outpatient setting.
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% 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.
Nutritional Counseling
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% No cost sharing applies to the first 2 visits with a Primary Care Physician. Deductible then coinsurance apply after the first 2 visits with a Primary Care Physician per member
Reconstructive Surgery
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Provided in a Hospital- Acute Inpatient setting.
Gender Affirming Care
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Provided in a Hospital- Acute Inpatient setting.
Diabetes Care Management
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% No cost sharing applies to the first 2 visits with a Primary Care Physician. Deductible then coinsurance apply after the first 2 visits with a Primary Care Physician per member
Inherited Metabolic Disorders – PKU
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Off Label Prescription Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Dental Anesthesia
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Provided in a Hospital- Acute Inpatient setting.
Early Intervention Services
Covered
No Charge No ChargeNot Applicable 100.00%40.0 Visit(s) per Year For Members under the age of 3
Bone Marrow Transplant
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% Provided in a Hospital- Acute Inpatient setting.
Inpatient Rehabilitation Services
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%100.0 Days per Year
Wigs
Covered
Not Applicable 20.00% Coinsurance after deductibleNot Applicable 100.00%
Low Protein Foods
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%
Applied Behavior Analysis Based Therapies
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00% No cost sharing applies to the first 2 Mental Health outpatient office visits per member. Deductible then coinsurance apply after the first 2 Mental Health outpatient office visits per member
Convenience Care Clinic
Covered
No Charge after deductible No Charge after deductibleNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following NH Local Choice HMO Bronze 8000 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for NH Local Choice HMO Bronze 8000 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for NH Local Choice HMO Bronze 8000?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents