NH Local Choice HMO Silver 4000
59025NH0370056
Silver
HMO
NH Local Choice HMO Silver 4000 is a Silver HMO plan by Harvard Pilgrim Health Care of NE.
IMPORTANT: You are viewing the 2023 version of NH Local Choice HMO Silver 4000 59025NH0370056. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
NH Local Choice HMO Silver 4000 is offered in the following counties.
No data was found
Plan Overview
This is a plan overview for 2023 version of NH Local Choice HMO Silver 4000 59025NH0370056.
| Insurer: | Harvard Pilgrim Health Care of NE |
| Network Type: | HMO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 59025NH0370056 |
Cost-Sharing Overview
NH Local Choice HMO Silver 4000 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for NH Local Choice HMO Silver 4000 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8,700.00 | $8700 per person | $17400 per group |
| Deductible: | $4,000.00 | $4000 per person | $8000 per group |
| Coinsurance: | 0.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for NH Local Choice HMO Silver 4000 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $4,000.00 |
| Copayment: | $1,100.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
| Deductible: | $400.00 |
| Copayment: | $1,500.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
| Deductible: | $2,400.00 |
| Copayment: | $200.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
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 Silver 4000?
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 Silver 4000 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 Silver 4000 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 Silver 4000 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 | $40.00 | 100.00% | |
| Specialist Visit Covered | $80.00 Copay after deductible | 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $60.00 | 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | No Charge after deductible No Charge after deductible | 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | No Charge after deductible No Charge after deductible | 100.00% | |
| Hospice Services Covered | No Charge after deductible No Charge after deductible | 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 | $40.00 | 100.00% | 1 Exam(s) per 2 Years For Members age 19 and over |
| Urgent Care Centers or Facilities Covered | $50.00 | 100.00% | |
| Home Health Care Services Covered | No Charge after deductible No Charge after deductible | 100.00% | |
| Emergency Room Services Covered | $500.00 Copay after deductible | $500.00 Copay after deductible | |
| Emergency Transportation/Ambulance Covered | No Charge after deductible No Charge after deductible | No Charge after deductible No Charge after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | $1000.00 Copay per Stay after deductible | 100.00% | |
| Inpatient Physician and Surgical Services Covered | No Charge after deductible No Charge after deductible | 100.00% | |
| Bariatric Surgery Covered | $1000.00 Copay after deductible | 100.00% | Provided in a Hospital- Acute Inpatient setting. |
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | $1000.00 Copay per Stay after deductible | 100.00% | 100 Days per Year |
| Prenatal and Postnatal Care Covered | No Charge No Charge | 100.00% | Routine Prenatal and Postnatal Care are covered in full. |
| Delivery and All Inpatient Services for Maternity Care Covered | $1000.00 Copay after deductible | 100.00% | |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 | 100.00% | |
| Mental/Behavioral Health Inpatient Services Covered | $1000.00 Copay per Stay after deductible | 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 | 100.00% | |
| Substance Abuse Disorder Inpatient Services Covered | $1000.00 Copay per Stay after deductible | 100.00% | |
| Generic Drugs Covered | $10.00 | 100.00% | |
| Preferred Brand Drugs Covered | $60.00 | 100.00% | |
| Non-Preferred Brand Drugs Covered | 35.00% Coinsurance after deductible | 100.00% | |
| Specialty Drugs Covered | 40.00% Coinsurance after deductible | 100.00% | Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered. |
| Outpatient Rehabilitation Services Covered | $60.00 | 100.00% | 60 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 | $60.00 | 100.00% | 60 Visit(s) per Year |
| Chiropractic Care Covered | $40.00 | 100.00% | |
| Durable Medical Equipment Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Hearing Aids Covered | 50.00% | 100.00% | |
| Imaging (CT/PET Scans, MRIs) Covered | $75.00 Copay after deductible | 100.00% | |
| Preventive Care/Screening/Immunization Covered | No Charge No Charge | 100.00% | |
| Routine Foot Care Covered | $80.00 Copay after deductible | 100.00% | Excluded for all diagnosis, except for the treatment of diabetes. |
| Acupuncture Covered | $40.00 | 100.00% | |
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | $40.00 | 100.00% | 1 Exam(s) per Year For Members under the age of 19 |
| Eye Glasses for Children Covered | 50.00% | 50.00% | 1 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 | $60.00 | 100.00% | 60 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 | $60.00 | 100.00% | 60 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 Charge | 100.00% | |
| Laboratory Outpatient and Professional Services Covered | No Charge after deductible No Charge after deductible | 100.00% | |
| X-rays and Diagnostic Imaging Covered | No Charge after deductible No Charge after deductible | 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 | $1000.00 Copay after deductible | 100.00% | Provided in a Hospital- Acute Inpatient setting. |
| Accidental Dental Covered | $40.00 | 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. |
| Dialysis Covered | No Charge after deductible No Charge after deductible | 100.00% | Provided in a Hospital-Outpatient setting. |
| Allergy Testing Covered | No Charge after deductible No Charge after deductible | 100.00% | |
| Chemotherapy Covered | No Charge after deductible No Charge after deductible | 100.00% | Provided in a Hospital-Outpatient setting. |
| Radiation Covered | No Charge after deductible No Charge after deductible | 100.00% | Provided in a Hospital-Outpatient setting. |
| Diabetes Education Covered | $80.00 Copay after deductible | 100.00% | |
| Prosthetic Devices Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Infusion Therapy Covered | No Charge after deductible No Charge after deductible | 100.00% | Provided in a Hospital-Outpatient setting. |
| Treatment for Temporomandibular Joint Disorders Covered | No Charge after deductible No Charge after deductible | 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 | $40.00 | 100.00% | |
| Reconstructive Surgery Covered | $1000.00 Copay after deductible | 100.00% | Provided in a Hospital- Acute Inpatient setting. |
| Gender Affirming Care Covered | $1000.00 Copay after deductible | 100.00% | Provided in a Hospital- Acute Inpatient setting. |
| Diabetes Care Management Covered | $40.00 | 100.00% | |
| Inherited Metabolic Disorders – PKU Covered | No Charge after deductible No Charge after deductible | 100.00% | |
| Off Label Prescription Drugs Covered | 35.00% Coinsurance after deductible | 100.00% | |
| Dental Anesthesia Covered | No Charge after deductible No Charge after deductible | 100.00% | Provided in a Hospital- Acute Inpatient setting. |
| Early Intervention Services Covered | No Charge No Charge | 100.00% | 40 Visit(s) per Year For Members under the age of 3 |
| Bone Marrow Transplant Covered | $1000.00 Copay after deductible | 100.00% | Provided in a Hospital- Acute Inpatient setting. |
| Inpatient Rehabilitation Services Covered | $1000.00 Copay after deductible | 100.00% | 100 Days per Year |
| Wigs Covered | 20.00% Coinsurance after deductible | 100.00% | |
| Low Protein Foods Covered | No Charge after deductible No Charge after deductible | 100.00% | |
| Applied Behavior Analysis Based Therapies Covered | $40.00 | 100.00% | |
| Convenience Care Clinic Covered | $40.00 | 100.00% |
Free Preventive Services
There is no copayment or coinsurance for any of the following NH Local Choice HMO Silver 4000 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for NH Local Choice HMO Silver 4000 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 Silver 4000?
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