2024 Schedules of Benefits and SBCs: Rhode Island

Small group effective 1/1/24

HMO - OFF EXCHANGE with dental SOBSBC
HMO 1000 MD0000201288
HMO 1500 MD0000201289
HMO 1500 Value MD0000201312
HMO 2000/0% MD0000201290
HMO 2000/20% MD0000201291
HMO 3000/20% MD0000201293
HMO HSA 7250 MD0000201299
HMO HSA 1600 MD0000201286
HMO HSA 2500 MD0000201297
HMO HSA 3000 MD0000201298
HMO 500 MD0000201284
HMO 3000/0% MD0000201292
HMO 4000 MD0000201294
HMO 5000 MD0000201295
HMO 6000 MD0000201296
HMO - OFF EXCHANGE without dental SOBSBC
HMO 1000 MD0000201288
HMO 1500 MD0000201289
HMO 1500 Value MD0000201312
HMO 2000/0% MD0000201290
HMO 2000/20% MD0000201291
HMO 3000/20% MD0000201293
HMO HSA 7250 MD0000201299
HMO HSA 1600 MD0000201286
HMO HSA 2500 MD0000201297
HMO HSA 3000 MD0000201298
HMO 500 MD0000201284
HMO 3000/0% MD0000201292
HMO 4000 MD0000201294
HMO 5000 MD0000201295
HMO 6000 MD0000201296
PPO - OFF EXCHANGE with dental SOBSBC
PPO 1000 MD0000201300
PPO 1500 MD0000201301
PPO 2000/0% MD0000201302
PPO 2000/20% MD0000201303
PPO 3000/20% MD0000201305
PPO HSA 7250 MD0000201311
PPO HSA 1600 MD0000201287
PPO HSA 2500 MD0000201309
PPO HSA 3000 MD0000201310
PPO 500 MD0000201285
PPO 3000/0% MD0000201304
PPO 4000 MD0000201306
PPO 5000 MD0000201307
PPO 6000 MD0000201308
PPO - OFF EXCHANGE without dental SOBSBC
PPO 1000 MD0000201300
PPO 1500 MD0000201301
PPO 2000/0% MD0000201302
PPO 2000/20% MD0000201303
PPO 3000/20% MD0000201305
PPO HSA 7250 MD0000201311
PPO HSA 1600 MD0000201287
PPO HSA 2500 MD0000201309
PPO HSA 3000 MD0000201310
PPO 500 MD0000201285
PPO 3000/0% MD0000201304
PPO 4000 MD0000201306
PPO 5000 MD0000201307
PPO 6000 MD0000201308